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Gardner Yelton SE, Gatti J, Adil M, Guryildirim M, Tekes A, Sun LR. Risk Factors and Imaging Biomarkers Associated With Perioperative Stroke in Pediatric Moyamoya Arteriopathy. J Child Neurol 2022; 37:963-969. [PMID: 36128779 DOI: 10.1177/08830738221125554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with moyamoya arteriopathy are at high risk for developing ischemic stroke in the perioperative period. We sought to evaluate whether preoperative clinical and neuroimaging biomarkers are associated with postoperative stroke and transient ischemic attack in children with moyamoya following revascularization surgery. We performed a retrospective chart review of pediatric patients who underwent revascularization surgery for moyamoya in the last 15 years. Fifty-three patients who underwent 69 surgeries met the inclusion criteria. We recorded clinical predictors of stroke or transient ischemic attack within 7 days following surgery. We used Suzuki stage and Composite Cerebrovascular Stenosis Score to analyze neuroimaging. Significant risk factors for developing postoperative stroke or transient ischemic attack were younger age at surgery (P = .004) and transient ischemic attack less than 1 month prior to surgery (P < .001). Children under 5 and those with recent preoperative ischemic events should be the focus of investigation to evaluate modifiable risk factors and targeted interventions.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesia and Critical Care Medicine, 1500Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John Gatti
- 1500Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Malik Adil
- Department of Neurology, 1500Johns Hopkins School of Medicine, Baltimore MD, USA.,Stroke Branch, National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Melike Guryildirim
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, 1500Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, 1500Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Lisa R Sun
- Division of Pediatric Neurology, 1500Johns Hopkins School of Medicine, Baltimore MD, USA
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Davila-Williams D, Barry M, Vargas C, Vossough A, Bernard TJ, Rafay MF. Cerebral Arteriopathies of Childhood - Current Approaches. Semin Pediatr Neurol 2022; 43:101004. [PMID: 36344018 DOI: 10.1016/j.spen.2022.101004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022]
Abstract
Up to more than half of previously healthy children presenting with their first arterial ischemic stroke have a cerebral arteriopathy. Cerebral arteriopathies during childhood can be congenital, reflecting abnormal vessel development, or acquired when caused by disruption of vascular homeostasis. Distinguishing different types of cerebral arteriopathies in children can be challenging but of great clinical value as they may dictate different disease and treatment courses, and clinical and radiologic outcomes. Furthermore, children with stroke due to a specific arteriopathy exhibit distinctive features when compared to those with stroke due to other causes or a different type of arteriopathy. These features become crucial in the management of pediatric stroke by choosing appropriate diagnostic and treatment strategies. The objective of this article is to provide the reader with a comprehensive up-to-date review of the classification, symptoms, diagnosis, treatment, and outcome of cerebral arteriopathies in children.
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Affiliation(s)
| | - Megan Barry
- Section of Neurology, Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado, Aurora, Co, USA
| | - Carolina Vargas
- Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Arastoo Vossough
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy J Bernard
- Section of Neurology, Department of Pediatrics, Hemophilia & Thrombosis Center, University of Colorado, Aurora, Co, USA
| | - Mubeen F Rafay
- Children's Hospital Winnipeg, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Children's Hospital Research Institute of Manitoba, Manitoba, Canada.
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Brosius SN, Vossough A, Fisher MJ, Lang SS, Beslow LA, George BJ, Ichord R. Characteristics of Moyamoya Syndrome in Pediatric Patients With Neurofibromatosis Type 1. Pediatr Neurol 2022; 134:85-92. [PMID: 35849956 DOI: 10.1016/j.pediatrneurol.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moyamoya syndrome (MMS) is a progressive cerebral arteriopathy with increased incidence in children with neurofibromatosis type 1 (NF1). Despite the potential for significant neurological morbidity including stroke, little is known about the natural history, and no guidelines exist for screening and management of NF1-associated MMS. METHODS We identified 152 literature cases of children aged ≤18 years with NF1-associated MMS. A meta-analysis was performed evaluating clinical and neuroimaging findings and patient outcomes. Data from 19 patients with NF1-associated MMS from our center treated from January 1995 to July 2020 were abstracted via chart review and similarly analyzed for clinical and neuroimaging features. RESULTS Meta-analysis of literature cases showed a median age of MMS diagnosis of 6 years (interquartile range 3 to 10.8 years). Optic pathway gliomas were more common in patients with MMS (42%) compared with historical prevalence. Stroke or transient ischemic attack (TIA) was present at diagnosis in 46%. TIA and stroke were more common in patients with bilateral versus unilateral MMS (62% vs 34%, P = 0.001) and in children aged <4 years versus those aged ≥4 years (61% vs 40%, P = 0.02). Compared with the literature cases, our cohort was more frequently asymptomatic (42% vs 25%) and less likely to present with TIA or stroke (32% vs 46%) at diagnosis. CONCLUSIONS These data suggest there is an aggressive form of MMS in children with NF1 <4 years of age. Therefore, early screening should be considered to facilitate early detection and treatment of cerebral arteriopathy.
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Affiliation(s)
- Stephanie N Brosius
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Arastoo Vossough
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Fisher
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shih-Shan Lang
- Department of Neurosurgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brandon J George
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania; Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Rebecca Ichord
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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4
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Slavova N, Fullerton HJ, Hills NK, Breiding PS, Mackay MT, Steinlin M. Validation of the focal cerebral arteriopathy severity score (FCASS) in a Swiss cohort: Correlation with infarct volume and outcome. Eur J Paediatr Neurol 2020; 28:58-63. [PMID: 32826156 DOI: 10.1016/j.ejpn.2020.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/09/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Focal cerebral arteriopathy (FCA), a major cause of childhood arterial ischemic stroke (AIS), can progress and lead to increased infarct size and/or recurrent stroke. Evaluating treatment options depends on the ability to quantify reliably the degree of stenosis in FCA. AIMS We validated the recently introduced FCA severity score (FCASS) in an independent cohort from the Swiss Neuro-Paediatric Stroke Registry (SNPSR). MATERIALS AND METHODS We included children with FCA who had MR or CT angiography and a Pediatric Stroke Outcome Measure (PSOM) at 6-months and 2-years post-stroke. A paediatric neuroradiologist applied the FCASS and the modified pediatric Alberta Stroke Program Early Computed Tomography Score (ASPECTS), a measure of infarct volume, to all available imaging. Two senior paediatric stroke neurologists and a neuroradiology fellow independently assigned FCASS scores to test interrater reliability. Pairwise correlations between FCASS, pedASPECTS, and PSOM were examined. RESULTS Thirty-two children [median (IQR) age = 5.9 (1.8, 9.6), 19 males] were included. The median maximum FCASS score at any time was 9 (IQR 6, 12; range 3, 16). Larger infarct volume scores correlated with both higher maximum FCASS scores and worse post-stroke outcomes, although we found no direct correlation between FCASS and outcomes. Stroke neurologists tended to assign lower FCASS scores than the neuroradiologist, but interrater reliability was predominantly good. CONCLUSIONS In this independent validation cohort, higher maximum FCASS correlated with greater infarct volume scores that also correlated with worse neurological outcomes. Scoring by non-imaging specialists seems to be valuable, although differences are present.
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Affiliation(s)
- Nedelina Slavova
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Inselspital, and University of Bern, Switzerland; Department of Interventional, Pediatric and Diagnostic Radiology, Inselspital, University Hospital, and University of Bern, Switzerland.
| | | | - Nancy K Hills
- Department of Neurology, University of California, San Francisco, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Philipe S Breiding
- Department of Diagnostic and Interventional Radiology, Kantonsspital Frauenfeld, Switzerland
| | - Mark T Mackay
- Royal Children's Hospital and Murdoch Children's Research Institute, University of Melbourne, Australia
| | - Maja Steinlin
- Division of Neuropaediatrics, University Hospital Inselspital, and University of Bern, Switzerland
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Guilliams KP, Fields ME, Dowling MM. Advances in Understanding Ischemic Stroke Physiology and the Impact of Vasculopathy in Children With Sickle Cell Disease. Stroke 2019; 50:266-273. [PMID: 30661504 DOI: 10.1161/strokeaha.118.020482] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Kristin P Guilliams
- From the Department of Neurology (K.P.G.), Washington University School of Medicine, St Louis, MO.,Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Melanie E Fields
- Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Michael M Dowling
- Department of Pediatrics and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.M.D.)
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Fullerton HJ, Stence N, Hills NK, Jiang B, Amlie-Lefond C, Bernard TJ, Friedman NR, Ichord R, Mackay MT, Rafay MF, Chabrier S, Steinlin M, Elkind MSV, deVeber GA, Wintermark M. Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History. Stroke 2019; 49:2590-2596. [PMID: 30355212 DOI: 10.1161/strokeaha.118.021556] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.
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Affiliation(s)
- Heather J Fullerton
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Pediatrics (H.J.F.), University of California, San Francisco
| | - Nicholas Stence
- Department of Radiology (N.S.), University of Colorado, Denver
| | - Nancy K Hills
- From the Department of Neurology (H.J.F., N.K.H.), University of California, San Francisco.,Department of Biostatistics and Epidemiology (N.K.H.), University of California, San Francisco
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
| | | | | | - Neil R Friedman
- Center for Pediatric Neurosciences, Neurological Institute, Cleveland Clinic, OH (N.R.F.)
| | - Rebecca Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine of the University of Pennsylvania (R.I.)
| | - Mark T Mackay
- Department of Paediatrics, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Victoria, Australia (M.T.M.)
| | - Mubeen F Rafay
- Department of Pediatrics and Child Health, Children's Hospital, University of Manitoba, Winnipeg, Canada (M.F.R.)
| | - Stéphane Chabrier
- INSERM, UMR1059 Sainbiose, University of Lyon, CHU Saint-Étienne, France (S.C.)
| | - Maja Steinlin
- Department of Pediatric Neurology, University Children's Hospital, University of Bern, Switzerland (M.S.)
| | - Mitchell S V Elkind
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY.,Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York, NY
| | | | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, CA (B.J., M.W.)
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deVeber G, Kirkham F, Shannon K, Brandão L, Sträter R, Kenet G, Clausnizer H, Moharir M, Kausch M, Askalan R, MacGregor D, Stoll M, Torge A, Dlamini N, Ganesan V, Prengler M, Singh J, Nowak-Göttl U. Recurrent stroke: the role of thrombophilia in a large international pediatric stroke population. Haematologica 2019; 104:1676-1681. [PMID: 30679327 PMCID: PMC6669164 DOI: 10.3324/haematol.2018.211433] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 12/04/2022] Open
Abstract
Risk factors for arterial ischemic stroke in children include vasculopathy and prothrombotic risk factors but their relative importance to recurrent stroke is uncertain. Data on recurrent stroke from databases held in Canada (Toronto), Germany (Kiel-Lübeck/Münster), and the UK (London/Southampton) were pooled. Data were available from 894 patients aged 1 month to 18 years at first stroke (median age, 6 years) with a median follow-up of 35 months. Among these 894 patients, 160 (17.9%) had a recurrence between 1 day and 136 months after the first stroke (median, 3.1 months). Among 288 children with vasculopathy, recurrence was significantly more common [hazard ratio (HR) 2.5, 95% confidence interval (95% CI) 1.92-3.5] compared to the rate in children without vasculopathy. Adjusting for vasculopathy, isolated antithrombin deficiency (HR 3.9; 95% CI: 1.4-10.9), isolated elevated lipoprotein (a) (HR 2.3; 95% CI: 1.3-4.1), and the presence of more than one prothrombotic risk factor (HR 1.9; 95% CI: 1.12-3.2) were independently associated with an increased risk of recurrence. Recurrence rates calculated per 100 person-years were 10 (95% CI: 3-24) for antithrombin deficiency, 6 (95% CI: 4-9) for elevated lipoprotein (a), and 13 (95% CI: 7-20) for the presence of more than one prothrombotic risk factor. Identifying children at increased risk of a second stroke is important in order to intensify measures aimed at preventing such recurrences.
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Affiliation(s)
| | - Fenella Kirkham
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK.,University Hospital Southampton, UK
| | | | | | - Ronald Sträter
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany
| | - Gili Kenet
- Pediatric Coagulation Service, National Hemophilia Centre and Institute of Thrombosis and Hemostasis Sheba Medical Center, Tel-Hashomer, Israel
| | - Hartmut Clausnizer
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Martina Kausch
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | | | - Monika Stoll
- Department of Genetic Epidemiology, University of Münster, Münster, Germany
| | - Antje Torge
- Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
| | | | - Vijeja Ganesan
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mara Prengler
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Ulrike Nowak-Göttl
- Department of Paediatric Haematology/Oncology, University of Münster, Münster, Germany .,Institute of Clinical Chemistry, University Hospital Kiel-Lübeck, Kiel, Germany
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Stacey A, Toolis C, Ganesan V. Rates and Risk Factors for Arterial Ischemic Stroke Recurrence in Children. Stroke 2018. [DOI: 10.1161/strokeaha.117.020159] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Arthur Stacey
- From the Department of Clinical Neuroscience, UCL Institute of Neurology, London, United Kingdom (A.S.); Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom (C.T.); and Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom (V.G.)
| | - Claire Toolis
- From the Department of Clinical Neuroscience, UCL Institute of Neurology, London, United Kingdom (A.S.); Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom (C.T.); and Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom (V.G.)
| | - Vijeya Ganesan
- From the Department of Clinical Neuroscience, UCL Institute of Neurology, London, United Kingdom (A.S.); Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom (C.T.); and Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom (V.G.)
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9
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Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017; 135:e146-e603. [PMID: 28122885 PMCID: PMC5408160 DOI: 10.1161/cir.0000000000000485] [Citation(s) in RCA: 6014] [Impact Index Per Article: 859.1] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3722] [Impact Index Per Article: 413.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Fullerton HJ, Wintermark M, Hills NK, Dowling MM, Tan M, Rafay MF, Elkind MSV, Barkovich AJ, deVeber GA. Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study. Stroke 2015; 47:53-9. [PMID: 26556824 DOI: 10.1161/strokeaha.115.011173] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Published cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20%. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era. METHODS The Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review. RESULTS Of the 355 children, 354 survived their acute index stroke, and 308 (87%) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8% (95% confidence interval, 4.6%-10%) at 1 month and 12% (8.5%-15%) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95% confidence interval, 1.8-14). The 1-year recurrence rate was 32% (95% confidence interval, 18%-51%) for moyamoya, 25% (12%-48%) for transient cerebral arteriopathy, and 19% (8.5%-40%) for arterial dissection. CONCLUSIONS Children with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed.
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Affiliation(s)
- Heather J Fullerton
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
| | - Max Wintermark
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Nancy K Hills
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Michael M Dowling
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Marilyn Tan
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Mubeen F Rafay
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Mitchell S V Elkind
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - A James Barkovich
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
| | - Gabrielle A deVeber
- From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.)
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