Azathioprine and Aspirin in Childhood Primary Arterial Stroke

Abstract

Objectives: The objectives of the study were to determine the complications of anticoagulants in acute phase, and of low dose Aspirin with and without Azathioprine in remission and maintenance phases in patients with arterial ischemic strokes (AIS). Study Type: observational and analytic. Place: The department of the Neurology of the Children’s Hospital Lahore-Pakistan. Setting and Duration: The study was conducted at the department of the Neurology of the Children's Hospital from 1st Jan 2009 to 31st December 2010. Methods: Over the period of 2 years, 68 patients with acute ischemic strokes were admitted, who presented within 14 days of onset of the symptoms. Patients with AIS were treated with anticoagulants at least for 04 weeks and this was followed by long term use of Aspirin. Patients ais due to progressive arteriopathy were treated with Azathioprine. Patient were followed in Hospital based cohort study at single center and were systemically assessed for clinical presentation, classification of choldhood primary ischaemic stroke (cPIS), adverse effects of anticoagulants, aspirin and azathioprine. Statistical Analysis: Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 12.0 (Chicago, IL). Frequencies were calculated for categorical data including gender, final outcome and complications of anticoagulation therapy. Result: 68 children with cPIS (boys 62%, girls 38%) with mean age of 8.5 years (median age 7.4 + 3.5 years), were enrolled in this study.The mean time-interval between the symptoms onset and the patients’ admission to the hospital was 5.6 days (range 1 to 14 days). Motor deficit (70%); headache (64%) and fever (20%) were the commonest symptoms, whereas, hemiparesis (60%); seizure 55 % (focal 35%, generalized 20%); and decreased conscious level (30%), were the commonest neurological findings. Neuroradiological findings of head revealed; ischemic strokes 50 (73.5%); hemorrhagic strokes 10 (14.7%) and ischaemic- haemorrhagic lesions 8(11.8%). Conventional angiography and/or MRA revealed that at the time of admission 51 (51/68, 75%) of the cohort had non-progressive (obliterative) and 17 (17/68,25%) had evidence of progressive arteriopathy. No secondary hemorrhagic was documented among infarcts strokes, who were treated with heparin and anticoagulants. Hospital outcome was as; survivors 56 (81.5%) and deaths 12 (18.5%). 40patints discharged on long term oral aspirin, and 14 children of these were commenced also on Azathioprine and are on follow-up. The Neurological findings among 56 survivors were; normal 20%; minor disabilities 25%; moderate disabilities 20% and severe disabilities 35%. Conclusions and Recommendations: The spectrum of cPIS in children includes both progressive and nonprogressive forms. Characteristic features at diagnosis can be used to predict later progression, and to guide selection of patients for immunosuppressive therapy. Further studies are required to substantiate our findings.