Arterial ischaemic stroke in children

Paradoxical Embolism in Juveniles and Young Adults With Severe-to-Profound Sudden Sensorineural Hearing Loss

Objective: Paradoxical embolism from right-to-left shunting is a common cause of cryptogenic stroke in the young. Circulatory ischemia of the cochlea is closely connected with severe-to-profound sudden sensorineural hearing loss. This study aimed to explore the role of paradoxical embolism in severe-to-profound sudden sensorineural hearing loss in juveniles and young adults. Methods: From August 2021 to September 2022, consecutive outpatients under 35 years of age with severe-to-profound sudden hearing loss were included in the study. Routine auditory electrophysiological testing and contrast transcranial Doppler ultrasonography (c-TCD) were conducted, and the results were retrospectively analyzed. Results: Seven patients (age: 19.4 ± 6.5 years) were enrolled, including 5 juveniles and 2 young adults. Three patients had severe deafness, and 4 patients had profound deafness. Right-to-left shunting was detected in all patients through c-TCD. Patent foramen ovale was found in 2 patients while pulmonary arteriovenous fistula was found in 1 patient through contrast transthoracic echocardiography or cardiac catheterization. No patients had precipitating factors for sudden sensorineural hearing loss, and none had abnormalities on head magnetic resonance imaging. Six patients underwent whole-exome sequencing, and no known deafness gene variant was detected. After standard treatment for 1 month, 2, 3, and 2 patients had complete, slight, and no hearing recovery, respectively. Conclusions: Paradoxical embolism is a possible cause of severe-to-profound sudden sensorineural hearing loss in juveniles and young adults. In young patients, c-TCD is an effective screening tool to detect right-to-left shunting, while contrast transthoracic echocardiography is a complementary examination to c-TCD.

Prevalence & Risk Factors for Perinatal Stroke: A Population-Based Study

Objectives

The study objective was to calculate the birth prevalence of perinatal stroke and examine risk factors in term infants. Some risk factors are present in healthy infants, making it difficult to determine at-risk infants.

Study Design

Prospective population-based perinatal stroke data were compared to the Australian general population data using chi-squared and Fisher's exact tests and multivariable logistic regression analysis.

Results

Sixty perinatal stroke cases were reported between 2017 and 2019. Estimated stroke prevalence was 9.6/100,000 live births/year including 5.8 for neonatal arterial ischemic stroke and 2.9 for neonatal hemorrhagic stroke. Eighty seven percent had multiple risk factors. Significant risk factors were cesarean section (p = 0.04), 5-min Apgar score <7 (p < 0.01), neonatal resuscitation (p < 0.01) and nulliparity (p < 0.01).

Conclusions

Statistically significant independent risk factors do not fully explain the cause of perinatal stroke, because they are not a direct causal pathway to stroke. These data now require validation in a case-control study.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

Predictors of Neurological Outcome of Arterial Ischemic Stroke in Children

Stroke is an important cause of mortality and morbidity in children. The aim of the study was to evaluate long-term neurological outcome in children with arterial ischemic stroke (AIS) and explore predictive factors that affect poor outcome. Fifty-six patients aged between 1 month and 17 years who were treated at M. Iashvili Children's Central Hospital, Tbilisi, Georgia, with an onset of stroke from 2007 to 2017 were included. To explore predictive factors of outcome, the following data were collected: demographic characteristics, risk factors, he presenting signs, radiological features, and presence of stroke recurrence. Neurological status at discharge and long-term neurological outcome at least 1 year after stroke was evaluated according to Pediatric Stroke Outcome Measure subscale. The reported outcome after childhood stroke was variable with long-term neurological deficits in one-third of patients (30.4%). The neurological outcome was worse in males, in patients with multiple stroke episodes, and in those with infarctions involving a combination of cortical and subcortical areas. Pediatric AIS carries the risk of long-term morbidity, and neuroimaging has a predictive influence on outcome.

Presentation of Acute Childhood Stroke in a Tertiary Pediatric Emergency Department

OBJECTIVES

The aim was to describe clinical presentation, management, and outcomes of stroke in a tertiary emergency department (ED) of a developing country.

METHODOLOGY

Retrospective case series of patients aged 1 month to 18 years presenting to an ED with radiological confirmed acute stroke during a 7-year period were studied.

RESULTS

Ninety-five patients were identified. Twenty-five patients were excluded because of incomplete records (8) or not presenting via ED (17). Thirty-four (48.5%) were diagnosed with hemorrhagic stroke (HS), 30 (42.8%) with arterial ischemic stroke (AIS), and 6 (8.5%) with sinus venous thrombosis (SVT). Mean age was 5.3 years, and 55.3% were male. The median time from onset of symptoms to ED presentation was 24 hours (mean, 55 hours; interquartile range [IQR], 14-72) for AIS, 24 hours (mean, 46.9 hours; IQR, 9-48) for HS, and 120 hours (mean,112 hours; IQR, 72-168) for SVT. Congenital cardiac disease was the most common risk factor (9%). For AIS, the most common symptoms were focal numbness 56.6% (95% confidence interval [CI], 37.8%-75.4%), focal weakness 56.6% (95% CI, 37.8%-75.4%), and seizures 50% (95% CI, 31%-68.8%). For HS, the most common symptoms were headache 64.7% (95% CI, 47.7%-81.6%), vomiting 79.4 (95% CI, 65-93.7), and altered mental status 64.7% (95% CI, 47.7-81.6). Computed tomography scan was done in 100% of the patients and magnetic resonance imaging in 54%. Twenty-five (36%) patients were admitted to intensive care unit and required intubation. Long-term deficit was identified in 24 (36%) patients based on medium-term follow-up.

CONCLUSIONS

The spectrum of stroke in a developing country was similar to published series from developed countries in terms of final diagnosis, risk factors, and delay to ED presentation, neuroimaging, and long-term neurodeficits. No tropical diseases were identified as risk factors.

Epidemiology, risk factors and characteristics of pediatric stroke: a nationwide population-based study

BACKGROUND

Stroke, classically characterized as an acute acquired neurological deficit, is an important leading cause of death and chronic morbidity in children.

AIMS

This study reported the period prevalence, incidence and risk factors of pediatric stroke in Taiwan.

METHODS AND PROCEDURES

All Taiwan inhabitants aged 1 month to 18 years registered in the National Health Insurance Research Database between 2010 and 2011 were enrolled in this study. Factors including age, sex, location and household income levels were collected. Incidence, period prevalence, mortality rate and the possible risks were completely evaluated. Outcomes and results: Hemorrhagic stroke has a significantly higher mortality rate than ischemic stroke (27.6% vs. 10.2%, P<0.05). Risk factors or underlying diseases for stroke were identified in 77.8% of the patients and 16.2% had more than one risk factor. The most common risk factors were vascular diseases (26.3%), infection (14.0%) and cardiac disorders (9.1%).

CONCLUSIONS AND IMPLICATIONS

Infants younger than 2 years, boys and children in lower socioeconomic status have a significantly higher risk of stroke. Hemorrhagic stroke has a significantly higher mortality rate than ischemic stroke. More than half of the children with stroke had underlying diseases and the causes of hemorrhagic stroke are significantly different from ischemic stroke.

[Clinical and neuroimaging signs of cardioembolic stroke in children]

AIM

To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children.

MATERIAL AND METHODS

A group of 100 patients with arterial ischemic stroke (AIS), aged from 1 month to 15 years, was stratified into the main group (10 patients with CES) and the comparison group (90 patients with other subtypes of AIS). CT and MRI, MR-angiography, ultrasound study as well as assessment of clinical symptoms on PedNIHSS were performed. The duration of follow-up was from 2 month to 14 years. The follow-up allowed the assessment of occurrence of secondary strokes, severity of residual neurological symptoms on the PSOM and fatal outcomes. Special attention was drawn to the use of CASSADE criteria for CES.

RESULTS AND CONCLUSION

Clinical features that help to diagnose CES, even in the absence of adequate neuroimaging, in patients with heart disease, which is a potential high risk factor for cardioembolia, were established. These factors include early disease onset, acute development and progression of neurological deficit to the maximal level in the first 5 min., marked severity of the acute period (PedNIHSS > 15), early recovery of neurological functions, significant residual neurological symptoms (PSOM > 2). These symptoms should be used in addition to the CASCADE criteria in the diagnosis of CES of AIS type in children.

[Clinical and neuroimaging signs of cardioembolic stroke laboratory in children]

AIM

To study clinical and neuroimaging signs of cardioembolic stroke (CES) in children.

MATERIAL AND METHODS

Ten children (mean age 3.5±3.5 years) were examined. Eight children met the diagnostic criteria of CES CASCADE, two children were diagnosed with CES based on the complex of symptoms. A comparison group consisted of 90 children with other subtypes of ischemic stroke (IS). The diagnosis was confirmed by MRI and magnetic-resonance angiography; symptom severity was assessed with PedNIHSS and PSOM.

RESULTS AND CONCLUSION

The PedNIHSS score in the acute stage of CES was higher (18.4±9.34) compared to patients with other subtypes of IS (12.6±6.2; p=0.0065). Six patients had large cerebral infarctions with the involvement of basal ganglia, internal capsule, white matter and cerebral cortex. In two patients, the infarction affected the cerebral cortex and underlying white matter, in one patient it affected the cortex from one side and the basal ganglia from the other. A damage of the cortex was noted in one patient. The frequency of recurrent CES was 30%, of fatal cases 20%. Recurrent IS and severe residual neurological deficit were more frequent in CES.

CONCLUSION

Early disease onset, acute development and progression of neurological deficit up to the maximal level in the first 5 min, marked severity of the acute stage (PedNIHSS score >15), early onset of neurological function recovery, marked residual neurological deficit (PSOM score >2) are the additional signs of CES.

Pediatric arterial ischemic stroke: Epidemiology, risk factors, and management

Pediatric arterial ischemic stroke (AIS) is an uncommon but important cause of neurologic morbidity in neonates and children, with consequences including hemiparesis, intellectual disabilities, and epilepsy. The causes of pediatric AIS are unique to those typically associated with stroke in adults. Familiarity with the risk factors for AIS in children will help with efficient diagnosis, which is unfortunately frequently delayed. Here we review the epidemiology and risk factors for AIS in neonates and children. We also outline consensus-based practices in the evaluation and management of pediatric AIS. Finally we discuss the outcomes observed in this population. While much has been learned in recent decades, many uncertainties sill persist in regard to pediatric AIS. The ongoing development of specialized centers and investigators dedicated to pediatric stroke will continue to answer such questions and improve our ability to effectively care for these patients.

Galanin's implications for post-stroke improvement

Stroke leads to a variety of pathophysiological conditions such as ischemic infarct, cerebral inflammation, neuronal damage, cognitive decline, and depression. Many endeavors have been tried to find the therapeutic solutions to attenuate severe neuropathogenesis after stroke. Several studies have reported that a decrease in the neuropeptide regulator ‘galanin’ is associated with neuronal loss, learning and memory dysfunctions, and depression following a stroke. The present review summarized recent evidences on the function and the therapeutic potential of galanin in post-ischemic stroke to provide a further understanding of galanin's role. Hence, we suggest that galanin needs to be considered as a therapeutic factor in the alleviation of post-stroke pathologies.

Outcome and recurrence 1 year after pediatric arterial ischemic stroke in a population-based cohort

OBJECTIVE

Arterial ischemic stroke (AIS) is an important cause of acquired brain injury in children. Few prospective population-based studies of childhood AIS have been completed. We aimed to investigate the outcome of childhood AIS 12 months after the event in a population-based cohort.

METHODS

Children aged 29 days to < 16 years with radiologically confirmed AIS occurring over a 1-year period residing in southern England (population = 5.99 million children) were eligible for inclusion. Outcome was assessed during a home visit using the Pediatric Stroke Outcome Measure (PSOM). Parental impressions of recovery were assessed using the Pediatric Stroke Recurrence and Recovery Questionnaire. PSOM score was estimated via telephone interview or clinician interview whenever home visit was not possible.

RESULTS

Ninety-six children with AIS were identified. Two children were lost to follow-up. Nine of 94 (10%) children died before the 12-month follow-up. One child had an AIS recurrence. PSOM scores were available for 78 of 85 living children at follow-up. Thirty-nine of 78 (50%) had a good outcome (total PSOM score < 1), and 39 of 78 (50%) had a poor outcome. Seizures at onset of AIS were associated with a poor outcome (odds ratio = 3.5, 95% confidence interval = 1.16-10.6). Twenty-eight of 73 (38%) children were judged by their carers to have fully recovered. Ten of 84 (12%) children had recurrent seizures, and 17 of 84 (20%) reported recurrent headaches.

INTERPRETATION

AIS carries a significant risk of mortality and long-term neurological deficit. However, the rates of mortality, recurrence, and neurological impairment were markedly lower in this study than previously published figures in the United Kingdom. Ann Neurol 2016;79:784-793.

Arterial ischemic stroke in children with cardiac disease

OBJECTIVE

To describe the spectrum of cardiac disorders, timing in relation to interventional procedures, and outcome in children with cardiac disease and arterial ischemic stroke (AIS).

METHODS

Children younger than 18 years with cardiac disease and radiologically confirmed AIS admitted to the Royal Children's Hospital Melbourne between 1993 and 2010 were retrospectively identified using ICD-9 and ICD-10 searches.

RESULTS

Seventy-six children with cardiac disease and radiologically confirmed AIS were identified with the median age at diagnosis of 5 months (interquartile range 0-58). Cardiac lesions included cyanotic congenital heart disease (CHD) in 42 (55%), acyanotic heart disease in 24 (29%), cardiomyopathies/myocarditis in 6 (8%), infective endocarditis in 3 (4%), and primary arrhythmias in 3 (4%). Stroke occurred following cardiac procedures in 52 patients (68%): 41 post cardiac surgery (4.6 strokes per 1,000 surgical procedures) and 11 post cardiac catheterization (1.7 strokes per 1,000 catheterizations). The median time from procedure to diagnosis of stroke was 3 days (interquartile range 2-7), with 68% (95% confidence interval 58%-79%) of strokes estimated to occur within the periprocedural period. Prevalence of periprocedural stroke varied by diagnostic category, but was most common in patients with cyanotic CHD undergoing palliative surgery (22/2,256, 1%) (p < 0.005). There were 3 AIS-related deaths, and 54 survivors (84%) had persisting neurologic deficits.

CONCLUSIONS

Infants with cyanotic CHD were most frequently affected by AIS during the periprocedural period. Prospective cohort studies are required to determine effective primary and secondary prevention strategies.

Prothrombotic risk factors and antithrombotic therapy in children with ischemic stroke

OBJECTIVE

Congenital and acquired prothrombotic disorders have been highlighted in a recent series of cerebrovascular stroke (CVS), with a controversial role in pathogenesis. The aim is to study some prothrombotic risk factors [activated protein C (APC) resistance, von Willebrand factor (vWF), anticardiolpin (ACL) antibodies and plasma homocysteine] in children with ischemic stroke, and to evaluate the role of aspirin and low molecular weight heparin (LMWH) in its management in relation to outcome.

METHODS

A total of 37 cases aged from 1 month to 15 years ( mean ± standard deviation 26.2 ± 35.7 months), diagnosed as ischemic stroke (>24 hours) were recruited. Complete blood count, prothrombin time and concentration, partial thromboplastin time, serum electrolytes, random blood sugar, C-reactive protein, electrocardiogram and echocardiography were done. Levels of APC resistance, vWF, ACL antibodies [immunoglobulin G (IgG) and immunoglobulin M (IgM)] and plasma homocysteine were estimated. A total of 25 cases received aspirin 3-5 mg /kg/d and 12 patients received LMWH as initial dose at 75 international units (IU)/kg subcutaneously (SC) then 10-25 IU/kg/day for 15 days in a nonrandomized fashion.

RESULTS

The levels of APC resistance, vWF, ACL antibodies (IgG and IgM) and plasma homocysteine were significantly higher in stroke cases than in controls. There was no significant difference between cases treated with aspirin and those with LMWH in all prothrombotic factors. Significant positive correlations were found between vWF and ACL antibodies (IgG and IgM) levels before treatment. Significant decrease in cognitive function was detected between cases treated with LMWH and those treated with aspirin.

CONCLUSION

Ischemic CVS in children is multifactorial. Thrombophilia testing should be performed in any child with CVS. Early use of aspirin improves the prognosis and has less effect on cognitive function.

Stroke in children with cardiac disease: report from the International Pediatric Stroke Study Group Symposium

BACKGROUND

Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multidisciplinary panel of clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke.

RESULTS

Significant knowledge gaps exist, including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment, and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain computed tomography and ultrasound have low rates of stroke detection, and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiologic barriers to research such as small patient numbers, heterogeneity of cardiac disease, and coexistence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5-10 years. The development of large-scale multicenter and multispecialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research.

CONCLUSIONS

There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. Although significant barriers to clinical research exist, multicenter and multispecialty collaboration is an important step toward advancing clinical care and research for children with cardiac disease and stroke.

Therapeutic benefits and side effects of Azathioprine and Aspirin in treatment of childhood primary arterial stroke

BACKGROUND

Childhood primary angiitis of central nervous system (cPACNS) is rare idiopathic vasculitis most frequently in adults. Children with this disorder can present with a range of neurological symptoms and signs including decreased consciousness, seizures, hemiparesis, cranial nerve deficits, and cognitive deficits. Delayed diagnosis and treatment may compromise the outcome. Therapeutic modalities including Anti-Platelet agents, Corticosteroids, Azathioprine, Cyclophosphamide and other Immunomodulatory agents have been used with variable success.

PURPOSE

We wanted to study a cohort of children with childhood primary angiitis of Central Nervous System (cPACNS); and evaluate efficacy and safety of their management.

METHODS

Current study is an observational cohort study that included 68 patients admitted with acute ischemic strokes (AIS) within 14 days of symptoms onset at Department of Neurosciences at Children's Hospital, Lahore, Pakistan from January 2009 to December 2010 with an age ≤16 years. They were subjected to physical examination laboratory and neuroimaging evaluation. They received pulses of intravenous steroids and/or Immunoglobulins for 4 weeks with maintenance dose of Azathioprine and low dose Aspirin for 24 months and kept on follow for 2 years.

RESULTS

Sixty eight patients were included; 42 (62.76%) boys and 26 (38.23%) girls whose mean age was 8.5 ± 3.5 years. Presenting symptoms and signs included fever (20%), headache (64%), disturbed consciousness (30%), seizures 55%, hemiparesis (60%), and motor deficit (70%). Neuroimaging studies revealed ischemic strokes in 50 patients (73.5%), hemorrhagic strokes in 10 (14.7%) and ischemic-hemorrhagic lesions in 8 (11.8%). Males with, deep coma and raised intracranial pressure were poor prognostic signs. Mortality was encountered in 12 patients (17.64%) with normal outcome in 11 (16.17%), minor disabilities in 14 (20.59%), moderate disabilities in 11 (16.17%) and severe disabilities in 20 (29.41%).

CONCLUSIONS

Characteristic features of cPACNS on presentation may predict later progression and outcome, identify high-risk patients which may guide selection of patients for immunosuppressive therapy. Further studies are required to substantiate our findings regarding immunosuppressive therapy for such patients.

Acute encephalopathy with unilateral cortical-subcortical lesions in two unrelated kindreds treated with glucocorticoids prenatally for congenital adrenal hyperplasia due to 21-hydroxylase deficiency: established facts and novel insight

BACKGROUND

Prenatal glucocorticoid (GC) treatment of the female fetus with 21-hydroxylase deficiency (21-OHD) may prevent genital virilization and androgen effects on the brain, but prenatal GC therapy is controversial because of possible adverse effects on fetal programming, the cardiovascular system and the brain.

CASE REPORTS

We report 2 patients with congenital adrenal hyperplasia (CAH) due to 21-OHD who were treated prenatally with dexamethasone, suffered from an acute encephalopathy and showed focal and multifocal cortical and subcortical diffusion restrictions in early MRI and signs of permanent alterations in the follow-up neuroimaging studies. Both patients recovered from the acute episode. Whereas the first patient recovered without neurological sequelae the second patient showed hemianopsia and spastic hemiplegia in the neurological follow-up examination.

CONCLUSION

These are 2 children with CAH, both treated prenatally with high doses of dexamethasone to prevent virilization. The question arises whether prenatal high-dose GC treatment in patients with CAH might represent a risk factor for brain lesions in later life. Adverse effects/events should be reported systematically in patients undergoing prenatal GC treatment and long-term follow-up studies involving risk factors for cerebrovascular disease should be performed.

Genetic polymorphism of β-fibrinogen gene-455G/A can contribute to the risk of ischemic stroke

Many studies have investigated the association between the β-fibrinogen gene-455G/A (FGβ-455G/A) polymorphism and the risk of ischemic stroke. However, these evidences were inadequate to provide stronger conclusions because most studies were generally small. To shed light on these inconclusive findings, we conducted a large sample size meta-analysis of studies relating to the FGβ-455G/A polymorphism and the risk of ischemic stroke. Odds ratios with a 95 % confidence interval were used to investigate the association between FGβ-455G/A polymorphism and ischemic stroke. Publication bias was tested by Egger's test and funnel plot. Inconsistency index and Cochran's Q statistic were used to check heterogeneity. Cumulative and recursive cumulative meta-analyses were performed to provide a framework for updating a genetic effect from all of the included studies. Twenty-six independent publications with 4,070 cases and 4,649 controls were included in this meta-analysis. Results showed that the β-fibrinogen-455G/A polymorphism was significantly associated with the risk of ischemic stroke. The FGβ-455G/A polymorphism was found to be a risk factor for ischemic stroke in Asians and adults, while association was not observed for Caucasians and juveniles based on the small size and it may be necessary to conduct larger studies on them to investigate the association in the future. The cumulative meta-analysis indicated a decline from 1998 to 2003, and the results remained stable during the period 2004-2012. The results indicate that FGβ-455G/A polymorphism may be a susceptible predictor of ischemic stroke. More studies are needed to elucidate the relationship further.

Extensive cerebral Sinovenous Thrombosis in a 5 Year Old Girl, Following Mild Dehydration. (Case Report and Review of Literature)

Abstract

Cerebral sinovenous thrombosis (CSVT) in children has rarely been reported in the literature, especially without underlying disorder. It has increasingly been diagnosed due to clinical awareness and sensitive neuroimaging techniques. The aim of this article was to report a case of cerebral sinovenous thrombosis without underlying disorder. We reported a 5 year old girl, presented with severe headache and seizure. She had a history of fever and diarrhea before the onset of headache. Neuroimaging showed evidence of CSVT on MRI and magnetic resonance venography. Investigations showed no inherited thrombophilia. The patient was treated with low molecular weight heparin (LMWH) which continued by warfarin. This case illustrated severe complications of dehydration in pediatrics without any evidence of underlying disorders.

Arterial ischemic stroke in children: 22 cases from southern Tunisia

The aim of this study is to review the cases of arterial ischemic stroke (AIS) in children in our department to evaluate the clinical and neuroimaging features, the etiologies and the treatment. This study retrospectively reviewed the records of all children aged between 1 month and 16 years who were admitted from 2000 to 2010 for AIS in the pediatrics department of Hedi Chaker University hospital in Sfax, Tunisia. Twenty-two children were enrolled. The average age at stroke was 3 years and 2 months. Cardiac disease (27%) and moyamoya disease (18%) were the most common etiologies. Adverse outcome after childhood stroke includes death in 9%, recurrence in 18% and neurologic deficits in 45%.

International Paediatric Stroke Study: stroke associated with cardiac disorders

BACKGROUND AND HYPOTHESIS

The aetiologies of arterial ischaemic stroke in children are diverse and often multifactorial. A large proportion occurs in children with cardiac disorders. We hypothesized that the clinical and radiographic features of children with arterial ischaemic stroke attributed to cardiac disorders would differ from those with other causes.

METHODS

Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders.

RESULTS

Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30.6%), congenital defects in 121/204 (59.3%), acquired in 40/204 (19.6%), and isolated patent foramen ovale in 31/204 (15.2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3.1 vs. 6.5 years; P < 0.001) and less likely to present with headache (25.6% vs. 44.6%; P < 0.001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P = 0.005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group.

CONCLUSIONS

Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a 'cardioembolic stroke pattern' with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation.

Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.

METHODS

The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

RESULTS

We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).

CONCLUSIONS

The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.

Safety of anticoagulants in children with arterial ischemic stroke

Pediatric arterial ischemic stroke (AIS) is increasingly diagnosed and carries significant risks of recurrence, morbidity, and mortality. Anticoagulant therapy (ACT) is commonly prescribed in childhood AIS. Hemorrhagic complication rates in pediatric stroke are unknown, and adult safety data are of limited applicability. We analyzed a prospectively enrolled cohort of children (aged 1 month-18 years) with acute AIS selected using standardized criteria for protocol-based ACT over14-year period. We assessed ACT-associated intracranial hemorrhage (ICH), including frequency, clinical and radiologic characteristics, predictors, and outcome. Among 215 children with AIS, 123 received ACT within 7 days after diagnosis. During anticoagulation, 14 (11%) children developed new or increased ICH, all within 26 days from diagnosis. ICH was symptomatic in 5 (4%), asymptomatic in 9 (7%), and mild (European Cooperative Acute Stroke Study grades HI1 or HI2) in all but 1 child (ECASS PH-2). Long-term neurologic outcomes after ACT-associated ICH in survivors were abnormal in 73% (8/11). Comparably, 12 of 75 (16%) children treated without anticoagulation developed new or increased ICH on follow-up imaging (P = .3507). We conclude that ACT is relatively safe in children with AIS, with a 4% risk of symptomatic ICH. Based on the safety of ACT in our study, clinical trials of ACT in childhood AIS are warranted.

Functional outcome following paediatric stroke

BACKGROUND

Paediatric stroke has a significant impact on functional ability; however, few studies describe outcomes using valid and reliable measures.

AIM

To describe functional abilities of children following ischemic stroke using a validated outcome measure.

METHODS

Eighteen children who had sustained an ischemic stroke were recruited from the stroke service of a tertiary children's hospital. The Pediatric Evaluation of Disability Inventory (PEDI) was used to describe functional abilities in domains of self-care, mobility and social function.

RESULTS

All children demonstrated lower functional skills and required more caregiver assistance than would be expected for their age. These findings were seen across all functional areas; however, self-care was more affected than mobility and social functions.

CONCLUSION

The PEDI provides a useful measure of functional outcomes following paediatric stroke. Children in this study demonstrated reduced abilities across all domains. Further research to investigate the relationship between location of injury and functional outcome would assist understanding of paediatric stroke outcomes.

Pediatric stroke: clinical findings and radiological approach

This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.

Pediatric stroke: clinical characteristics, acute care utilization patterns, and mortality

PURPOSE

Acute care utilization patterns are not well described but may help inform care coordination and treatment for pediatric stroke. The Kids Inpatient Database was queried to describe demographics and clinical characteristics of children with stroke, compare acute care utilization for hemorrhagic vs. ischemic stroke and Children's vs. non-Children's Hospitals, and identify factors associated with aggressive care and in-hospital mortality.

METHODS

Using a retrospective cohort of children hospitalized with stroke, demographics, predisposing conditions, and intensive (mechanical ventilation, advanced monitoring, and blood product administration) or aggressive (pharmacological therapy and/or invasive interventions) care were compared by stroke and hospital types. Factors associated with aggressive care or in-hospital mortality were explored using logistic regression.

RESULTS

Hemorrhagic stroke comprised 43% of stroke discharges, was more common in younger children, and carried greater mortality. Ischemic stroke was more common in older children and more frequently associated with a predisposing condition. Rates of intensive and aggressive care were low (30% and 15%), similar by stroke type, and greater at Children's Hospitals. Older age, hemorrhagic stroke, predisposing condition, and treatment at a Children's Hospital were associated with aggressive care. Hemorrhagic stroke and aggressive care were associated with in-hospital mortality.

CONCLUSIONS

Acute care utilization is similar by stroke type but both intensive and aggressive care are more common at Children's Hospitals. Mortality remains relatively high after pediatric stroke. Widespread implementation of treatment guidelines improved outcomes in adult stroke. Adoption of recently published treatment recommendations for pediatric stroke may help standardize care and improve outcomes.

Paediatric arterial ischaemic stroke and cerebral sinovenous thrombosis in Denmark 1994-2006: a nationwide population-based study

AIM

To assess the incidence rates (IR), clinical characteristics, risk factors, treatment and outcomes of paediatric arterial ischaemic stroke (AIS) and cerebral sinovenous thrombosis (CSVT).

METHODS

Using population-based, nationwide medical registries, we identified all patients aged 0-18 years at the time of hospitalization with first-ever AIS and/or CSVT in Denmark between 1994 and 2006. Medical records were retrieved and reviewed.

RESULTS

We identified 211 patients with AIS and 40 patients with CSVT corresponding to IRs of 1.33 (95% CI 1.16-1.52) and 0.25 (95% CI 0.19-0.34) per 100,000 person-years, respectively. The IRs peaked in infancy (<1 year) for both AIS and CSVT with an additional peak among adolescents (15-18 years) for CSVT. The IR of AIS increased 3.9% per year (p=0.036), whereas no changes were found for CSVT. In total, 48.2% of the patients received antithrombotic treatment; no major complications were observed. All-cause and thrombosis-related 30-day case fatality ratios were 3.6% and 2.4%, respectively; neurological sequelae were found in 56.2% of patients.

CONCLUSION

The IR of AIS was highest in infants and had increased with 3.9% annually during the observation period. The IR of CSVT had an additional peak in adolescence and remained unchanged over time.

Executive function following child stroke: the impact of lesion location

Child stroke is a major cause of death in children, although limited information exists on neurobehavioral functioning of stroke survivors. Executive function (important for goal-directed behavior) is thought to be vulnerable to early insults such as stroke because of its widespread representation in the immature brain. This study investigated the impact of lesion location on executive skills. Twenty-eight children diagnosed with stroke at least 18 months before assessment were recruited. Lesion characteristics were coded from magnetic resonance imaging (MRI) scans. Neurobehavioral assessment focused on cognitive and everyday executive skills. Deficits were found in the context of overall normal intellectual functioning (M = 91.60; SD = 19.40). Generally, insults involving frontal and extra-frontal regions impacted equally on cognitive performance. Everyday deficits were marginally more prominent following frontal insult. Subcortical frontal lesions were associated with impairments in everyday executive skills. Results provide further support for the diffuse representation of executive function in the immature brain.

Pharmacology in childhood arterial ischemic stroke

In recent years, there has been increasing recognition of the impact of childhood stroke and interest in the role of drugs in the acute, chronic, and prophylactic management of this condition. Most treatment strategies are based on studies in adults with stroke, and the relative infrequency of stroke and the heterogeneity of etiologies in childhood compared with adults present significant challenges in study design for childhood stroke studies. The presence of thrombophilia has been associated with stroke in children, strengthening the concept that antithrombotic, antiplatelet, and even thrombolytic agents have a role in stroke treatment and prevention. There are several potential roles for drugs in the treatment of childhood stroke including hyperacute therapy, antithrombotic medication, antiplatelet medication, and disease-specific medications. Herein, we review the use and rationale of these medications in childhood arterial ischemic stroke.

The epidemiology of childhood stroke

This paper reviews the epidemiology of childhood stroke. Stroke is an important condition in children. It is one of the top ten causes of childhood death and there is a high risk of serious morbidity for the survivors. Epidemiological data are an integral part of disease understanding and high quality studies are required to ensure that this data is robust. Incidence rates from population-based studies vary from 1.3 per 100,000 to 13.0 per 100,000. Factors found to influence incidence rates include age, gender, and ethnicity but there are also many inherent differences between studies. Temporal analysis of mortality rates from childhood stroke shows falling rates but there has been little long-term study of changes in incidence rates. Improved epidemiological data should be a goal of the national and international collaborative networks that are studying childhood stroke.

Epidemiology of childhood stroke in Estonia

We investigated the incidence and 30-day case-fatality of childhood stroke in Estonia, and clinical signs and risk factors of childhood stroke. A retrospective (1995-2003) and prospective study (2004-2006) of childhood stroke (arterial ischemic, hemorrhagic, and sinovenous thrombosis) and transient ischemic attack was conducted. Stroke-incidence calculation was based on the prospective study. Clinical diagnoses of stroke were confirmed by neuroradiology. The incidence rate of childhood stroke in Estonia was 2.73/100,000 person-years for children aged 30 days to 18 years: 1.61/100,000 for arterial ischemic stroke, 0.87/100,000 for hemorrhagic stroke, 0.25/100,000 for sinovenous thrombosis, and 0.37/100,000 for transient ischemic attack. No arterial ischemic stroke patients died within 30 days, but case-fatality for intracerebral hemorrhage was 46%. Focal signs occurred in 100% of arterial ischemic strokes and 64% of intracerebral hemorrhage cases. Risk factors were identified in 35/48 (73%) children with cerebrovascular attacks. Six children with arterial ischemic stroke (6/24, 25%) manifested more than one risk factor. The incidence rate of childhood stroke in Estonia is similar to that in earlier data.

Varicella vaccination and ischemic stroke in children: is there an association?

BACKGROUND

Ischemic stroke is a known complication of varicella disease. Although there have been case reports of ischemic stroke after varicella vaccination, the existence and magnitude of any vaccine-associated risk has not been determined. OBJECTIVE. The purpose of this work was to determine whether varicella vaccination is associated with an increased risk of ischemic stroke and encephalitis in children within 12 months after vaccination.

PATIENTS AND METHODS

We conducted a retrospective cohort study based on computerized data from children 11 months through 17 years old enrolled for > or =12 months in the Vaccine Safety DataLink from 1991 through 2004. International Classification of Disease codes identified cases of ischemic stroke (433-436, 437.1, 437.4, 437.6, 437.8-437.9) and encephalitis (052.0, 323.5, 323.8-9). Cox regression was used to model the risk in the 12 months after vaccination relative to all other person-time. Covariates included calendar time, gender, and stroke risk factors (eg, sickle cell disease).

RESULTS

Varicella vaccine was administered to 35.3% of the 3.2 million children in the cohort. There were 203 new inpatient ischemic stroke diagnoses, including 8 that occurred within 12 months after vaccination; there was no temporal clustering. The adjusted stroke hazard ratio was not elevated during any of the time periods in the 12 months after vaccination. Stroke was strongly associated with known risk factors such as sickle cell disease and cardiac disease. None of the 243 encephalitis cases occurred during the first 30 days after vaccination, and there was no association between encephalitis and varicella vaccination at any time in the 12 months after vaccination.

CONCLUSION

Our retrospective cohort study of >3 million children found no association between varicella vaccine and ischemic stroke.

Role of TNF-alpha gene variation in idiopathic childhood ischemic stroke: a case-control study

Etiology of the idiopathic childhood stroke remains unknown. In previous studies, the immunologic process may be involved in the idiopathic stroke. Tumor necrosis factor- alpha (TNF-alpha), an important immune mediator, may contribute to the initiation and progression in the stroke. The main purpose of this study was to investigate correlation of TNF-alpha genetic variation and idiopathic childhood ischemic stroke. Using the direct DNA sequencing method, polymorphisms in the TNF-alpha promoter region were genotyped in 67 Chinese patients with idiopathic childhood stroke and 70 controls. Among totally 7 single nucleotide polymorphisms identified in the TNF-alpha promoter region, the variant of the -863C/A is associated with increased risk of idiopathic childhood ischemic stroke in our study group. TNF-alpha molecule may have genetically as well as functionally an important role in the pathogenesis of idiopathic childhood ischemic stroke in the Chinese population.

Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).

Arterial ischemic stroke: experience in Chinese children

The aim of this study was to review cases of pediatric arterial ischemic stroke among Chinese subjects and thereby evaluate risk factors, clinical and neuroimaging features, and treatment, to establish a reasonable guideline for assessment and management of the disease. Between 1996 and 2006, 157 children (male:female ratio, 1.4:1) with arterial ischemic stroke were identified at Beijing Children's Hospital. The median age at stroke was 32 months (range, 4-192). Among patients with determined etiology, infections (12.1%), moyamoya disease (12.1%), and trauma (10.8%) were the most common. In 51 patients, there were no obvious risk factors (32.5%). Hemiplegia was the most common presenting feature (81.5%). The region of left middle cerebral artery was most frequently affected (36.3%), followed by the right middle cerebral artery (29.9%). Of the 157 patients, 56 were treated by intravenous thrombolytic agents (35.7%), all but one of them successfully (the one exception involving hemorrhagic complication). Randomized controlled trials are needed to establish primary prevention, acute treatment, and secondary prevention of pediatric ischemic stroke.

Risk of recurrent childhood arterial ischemic stroke in a population-based cohort: the importance of cerebrovascular imaging

OBJECTIVE

Few data exist regarding rates and predictors of recurrence after childhood arterial ischemic stroke. We sought to establish such rates within a large, multiethnic population and determine whether clinical vascular imaging predicts recurrence.

PATIENTS AND METHODS

In a population-based cohort study, we collected data on all documented cases of arterial ischemic stroke among 2.3 million children (<20 years old) enrolled in a northern Californian managed care plan from January 1993 to December 2004. Perinatal strokes were those that occurred by 28 days of life. Data on cerebrovascular imaging (conventional or magnetic resonance angiography), including presence of vascular abnormalities, were abstracted from official radiology reports. We used Kaplan-Meier survival-analysis techniques to determine rates and predictors of recurrent stroke.

RESULTS

Among 181 incident childhood stroke cases (84 perinatal; 97 later childhood), there were 16 recurrent strokes (1 after a perinatal stroke) at a median of 2.7 months. The 5-year cumulative recurrence rates were 1.2% after perinatal stroke and 19% after later childhood stroke. Of the 97 children with later childhood strokes, 52 received cerebrovascular imaging, predominantly magnetic resonance angiography (n = 36) and conventional angiography (n = 26). Although there were no recurrences among children with normal vascular imaging, children with a vascular abnormality had a 5-year cumulative recurrence rate of 66%.

CONCLUSIONS

Strokes recur in one fifth of cases of later childhood arterial ischemic stroke but are rare after perinatal stroke. Among the later childhood cases, cerebrovascular imaging identifies those at highest risk for recurrence.

Stroke following Glenn anastomosis in a child with inherited thrombophilia

The optimal anticoagulation following Fontan operation and its modifications remain controversial and it is even less well defined as regards patients with inherited thrombophilia. We present a case of a child with bidirectional Glenn anastomosis for double inlet left ventricle that suffered a stroke despite aspirin prophylaxis; the patient was combined homozygous for prothrombin G20210A mutation and for methylenetetrahydrofolate reductase C677T mutation as well. The family history was positive for fetal loss and premature cardiovascular disease. Large-scale studies are needed to evaluate whether carriers of thrombophilia mutations need more intense thromboprophylaxis.

Cerebrovascular disorders in childhood: etiology, clinical presentation, and neuroimaging findings in a case series study

OBJECTIVE: To describe the main etiologies, neurological manifestations and neuro-imaging findings among children with sequelae of cerebrovascular disorders. METHOD: Case series study of children whose diagnosis was stroke sequelae. Variables studied were age at the time of first episode, number of episodes, etiology, motor deficits, epilepsy, and effected vascular territory. RESULTS: Twenty three patients were studied. Average age at first episode was 6.91 (±2.08) years. Fourteen patients were female. The number of stroke events per patient ranged from one to five. The most frequent etiologies were heart disease and sickle cell anemia. The most frequent neurological deficit was right hemiparesis. Nine patients experienced seizures. The left middle cerebral artery was the most affected vascular area. CONCLUSION: Our findings are similar to those described in the literature. Despite a careful investigation, some causes of stroke remain unidentified.

Mutations and polymorphisms in genes affecting hemostasis proteins and homocysteine metabolism in children with arterial ischemic stroke

BACKGROUND

The pathogenesis of thrombosis in childhood seems to be multifactorial implicating genetic and environmental factors.

AIM

To compare the distributions of mutations/polymorphisms in genes affecting hemostasis (factor V Leiden - FVL, FV H1298R-FVR2, FII 20210A, b-Fib 455G>A, FXIII V34L, PAI-1 4G, HPA-1b) or homocysteine metabolism (MTHFR C677T, MTHFR A1298C) among 90 children with arterial ischemic stroke (AIS) and 103 controls, and to associate the carriage of these mutations/polymorphisms with their corresponding proteins in children with AIS.

RESULTS

AIS was more frequent in boys (p < 0.01). No studied mutation/polymorphism was found to be a risk factor for AIS, except for FVL [odds ratio 4.2 (95% CI 1.5-12.1)], the presence of which was even higher in 31 children with congenital AIS [odds ratio 6.82 (95% CI 2.0-22.8)]. FVL carriers had an odds ratio of 5.76 (95% CI 1.6-6.4) when FVR2 was absent. In thrombosed children, activated protein C resistance, prothrombin and fibrinogen levels were higher in the presence of FVL, FII20210A or b-Fib 455G-->A, respectively. Double heterozygotes in both MTHFR C677T and A1298T or homozygotes in one had significantly elevated homocysteine levels.

CONCLUSION

Except for FVL, no definite conclusion could be reached regarding the involvement of the studied mutations/polymorphisms in childhood AIS.

Family history is a poor screen for prothrombotic genes in children with stroke

OBJECTIVE

To evaluate family history of early pathological thrombosis as a screen for genetic prothrombotic risk factors in children with stroke.

STUDY DESIGN

A 5-year retrospective review of standardized pediatric stroke clinic evaluations of children with arterial ischemic stroke (AIS) or sinovenous thrombosis (SVT). A family history of early pathological thrombosis was defined as stroke, heart attack, or deep venous thrombosis before 50 years of age or multiple miscarriages in the parents or grandparents of the patient. We evaluated the association between family history and the presence of the Factor V Leiden mutation (FVL) and/or Prothrombin G20210A mutation (PTG) in these children.

RESULTS

The study included 68 children. Thirteen (19.1%) had a positive family history of early pathological thrombosis, nine (13.2%) were heterozygous for FVL, and one (1.5%) was heterozygous for PTG. Family history was not associated with the presence of FVL (p = .36) or FVL combined with PTG (p = .40). For FVL, family history had a positive predictive value of 23.1% and a negative predictive value of 89.1%.

CONCLUSION

A family history of early thrombosis is not associated with the presence of FVL or PTG in children with stroke. We recommend that all children with stroke receive a prothrombotic workup regardless of family history.