Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 2: Outcomes, Rehabilitation, and Transition to Adulthood.

Nontraumatic Pediatric Intracerebral Hemorrhage.

Maximizing Brain Health After Hemorrhagic Stroke: Bugher Foundation Centers of Excellence.

Stroke is relatively rare in children but has a significant impact on long-term morbidity and mortality. There are limited data regarding the etiology, clinical manifestation, and prognosis of arterial ischemic stroke (AIS) and hemorrhagic stroke (HS) in children. The aim of this study is to identify and compare etiology, risk factors, clinical manifestations, and prognostic outcomes between arterial ischemic and hemorrhagic pediatric stroke. We retrospectively reviewed all hospital medical records and pediatric neurology database of 83 children who were first diagnosed with AIS and HS at the Pediatric Department, Chiang Mai University Hospital, Chiang Mai, Thailand between January 1, 2009, and December 31, 2018. All children were from 1 month to 18 years old. Fifty-one AIS (56%) and 32 (35.2%) HS were identified. The median age of onset was 6.9 years for AIS and 5.3 years for HS. Moyamoya disease/syndrome was the most common cause in AIS (21.6%). Rupture of cerebral arteriovenous malformation was the most common cause in HS (21.9%). More than one-third (39%) of children had multiple risk factors associated with stroke. Iron deficiency anemia was commonly found in children with AIS (39.2%). The majority of clinical presentations were hemiparesis (80.4%) for AIS and alteration of consciousness (68.8%) for HS. The median time to diagnosis exceeded 6 hours in both AIS and HS. The overall mortality rate of acute stroke was 5.1 per 100 person-years (95% confidence interval [CI], 2.9-9). The mortality rate was higher in HS compared with that in AIS with statistical significance (16.6; 95% CI, 8.9-30.8 vs 1.1%; 95% CI, 0.3-4.6 per 100 person-years). Thirty children (36.1%) developed epilepsy during the follow-up (median duration, 26 months). Recurrent stroke occurred in 1 child with AIS and 1 child with HS. Moyamoya disease/syndrome and arteriovenous malformation rapture are the most common cause of AIS and HS, respectively. Iron deficiency anemia was commonly found in childhood AIS. The time to diagnosis in both AIS and HS was delayed. The mortality rate in HS was higher than in AIS. Neurological deficits are seen in 70% of childhood AIS during the follow-up. One-third of the children in our study developed epilepsy, which generally responds to a single antiseizure medication. The recurrence rate of childhood stroke was low compared with adult stroke.

Stroke is the second leading cause of death and the third leading cause of disability-adjusted life-years (DALYs) worldwide.1Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar, 2Murray CJ Vos T Lozano R Naghavi M et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6098) Google Scholar Moreover, the global burden of stroke is increasing. Between 1990 and 2010, the number of stroke-related deaths increased by 26% and DALYs by 19%.1Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar, 2Murray CJ Vos T Lozano R Naghavi M et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6098) Google Scholar Is this epidemic of stroke global or regional, and what is the explanation? A systematic review3Feigin VL Lawes CM Bennett DA Barker-Collo SL Parag V Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.Lancet Neurol. 2009; 8: 355-369Summary Full Text Full Text PDF PubMed Scopus (1830) Google Scholar of 56 population-based studies of the incidence and early case fatality of stroke, published from 1970 to 2008, showed that, in ten low-income and middle-income countries, the age-adjusted incidence of stroke more than doubled, from 52 per 100 000 person-years in 1970–79 to 117 per 100 000 person years in 2000–08—an increase of 5·6% per year. However, the incidence of stroke in 18 high-income countries almost halved, from 163 to 94 per 100 000 person-years—a decrease of 1% per year.3Feigin VL Lawes CM Bennett DA Barker-Collo SL Parag V Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.Lancet Neurol. 2009; 8: 355-369Summary Full Text Full Text PDF PubMed Scopus (1830) Google Scholar These data suggest divergent patterns of stroke epidemiology in different socioeconomic regions of the world, but might be subject to selection or sampling bias because of sampling of only ten of the world's low-income and middle-income countries over four decades, and diagnostic or stroke classification bias because of a failure to distinguish major pathological subtypes of stroke (ie, ischaemic vs haemorrhagic), which have different diagnostic criteria, causes, and outcomes. In The Lancet Global Health, Rita Krishnamurthi and colleagues from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and Stroke Expert Group estimate the incidence, mortality, and DALYs of first-ever ischaemic and haemorrhagic stroke (intracerebral and subarachnoid haemorrhage) in all 21 regions of the world in 1990, 2005, and 2010.4Krishnamurthi RV Feigin VL Forouzanfar MH Mensah GA et al.on behalf of the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study)the GBD Stroke Experts GroupGlobal and regional burden of ischaemic and haemorrhagic strokes in 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet Glob Health. 2013; (published online Oct 24.)http://dx.doi.org/10.1016/S2214-109X(13)70089-5Google Scholar The investigators derived the estimates from a systematic review of all relevant studies published between 1990 and 2010. 119 studies were identified in which pathological subtypes of stroke were confirmed by brain imaging or autopsy in at least 70% of cases. Specific analytical techniques were used to calculate regional and country-specific estimates of incidence and mortality rates and DALYs lost, by age group and country income status. Surprisingly, the major finding is that, in 2010, most of the global burden of stroke was due to haemorrhagic, not ischaemic, stroke. Haemorrhagic stroke constituted a third (31·5%) of the 16·9 million incident stroke events (20% in the high-income countries and 37% in the low-income and middle- income countries), which is higher than hitherto appreciated.4Krishnamurthi RV Feigin VL Forouzanfar MH Mensah GA et al.on behalf of the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study)the GBD Stroke Experts GroupGlobal and regional burden of ischaemic and haemorrhagic strokes in 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet Glob Health. 2013; (published online Oct 24.)http://dx.doi.org/10.1016/S2214-109X(13)70089-5Google Scholar However, despite being only half as common as ischaemic stroke, haemorrhagic stroke caused more than half (51·7%) of the 5·9 million stroke-related deaths, and three fifths (61·5%) of the 102·2 million DALYs lost throughout the world. The number of years of life lost were greater with haemorrhagic stroke because it affected people at a younger age (mean 65·1 years [SD 0·11]) than did ischaemic stroke (73·1 years [0·10]) and had a higher case fatality (57% vs 25%). The second major finding is that most of the burden of ischaemic and haemorrhagic stroke is in low-income and middle-income countries, which bear 63% of incident ischaemic strokes and 80% of haemorrhagic strokes, 57% of deaths due to ischaemic stroke and 84% due to haemorrhagic stroke, and 64% of DALYs lost due to ischaemic stroke and 86% due to haemorrhagic stroke. The average age of incident and fatal ischaemic and haemorrhagic strokes was 6 years younger in low-income and middle-income countries than in high-income countries. The third finding is that most of the burden of ischaemic and haemorrhagic stroke is in people younger than 75 years, who bear 62% of incident ischaemic strokes and 78% of haemorrhagic strokes, and 63% of DALYs lost due to ischaemic stroke and 83% due to haemorrhagic stroke. The fourth finding is that, over the past two decades (1990–2010) the absolute number of people with incident ischaemic stroke has increased significantly by 37% and incident haemorrhagic stroke by 47%, the number of deaths due to ischaemic stroke by 21% and haemorrhagic stroke by 20%, and the number of DALYs lost due to ischaemic stroke by 18% and haemorrhagic stroke by 14%. The increase in absolute numbers has arisen despite a reduction in the age-standardised incidence of ischaemic stroke by 13% and haemorrhagic stroke by 19%, a reduction in the mortality rates of ischaemic stroke by 37% and haemorrhagic stroke by 38%, and a reduction in DALYs rates of ischaemic stroke by 34% and haemorrhagic stroke by 39%. The reduction in rates probably shows improved education, prevention, diagnosis, treatment, and rehabilitation of stroke. The increase in absolute numbers, despite a reduction in rates, is presumably because global population growth and increasing life expectancy have increased the denominator by a greater proportion than the increasing number of stroke events has increased the numerator. The fifth finding is that the incidence of haemorrhagic stroke in low-income and middle-income countries is one rate that has increased over the past two decades (22% increase, 95% CI 5–30), particularly in people younger than 75 years (19%, 5–30). Indeed, low-income and middle-income countries had a 40% higher incidence, 77% higher mortality, and 65% higher DALY rates of haemorrhagic stroke than did high-income countries. Krishnamurthi and colleagues' results suggest that key priorities in the quest to reduce the global and regional burden of stroke are prevention of haemorrhagic stroke, particularly in low-income and middle-income countries, and in people younger than 75 years. Most haemorrhagic strokes can be attributed to hypertension and an unhealthy lifestyle (eg, physical inactivity, obesity, unhealthy diet, alcohol excess, and smoking; table).5Lawes CM Vander Hoorn S Rodgers A for the International Society of HypertensionGlobal burden of blood-pressure-related disease, 2001.Lancet. 2008; 371: 1513-1518Summary Full Text Full Text PDF PubMed Scopus (1708) Google Scholar, 6O'Donnell MJ Xavier D Liu L et al.on behalf of the INTERSTROKE investigatorsRisk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.Lancet. 2010; 376: 112-123Summary Full Text Full Text PDF PubMed Scopus (2049) Google ScholarTableRisk factors for haemorrhagic stroke in 663 cases of acute first haemorrhagic stroke (within 5 days of symptom onset) compared with 3000 controls with no history of stroke who were matched with cases for age and sex, assessed in 22 countries between 2007 and 20106O'Donnell MJ Xavier D Liu L et al.on behalf of the INTERSTROKE investigatorsRisk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.Lancet. 2010; 376: 112-123Summary Full Text Full Text PDF PubMed Scopus (2049) Google ScholarPrevalenceOdds ratio (99% CI)Population-attributable riskControlsCasesHistory of hypertension954/2996 (32%)399/662 (60%)3·8 (3·0–4·8)44% (37–52%)Regular physical activity362/2994 (12%)45/662 (7%)0·7 (0·4–1·1)28% (7–67%)Waist-to-hip ratio (T3 vs T1)984/2960 (33%)231/655 (35%)1·4 (1·02–1·9)26% (14–43%)Diet risk score (T3 vs T1)904/2982 (30%)221/658 (34%)1·4 (1·01–2·0)24% (12–43%)Alcohol intake*More than 30 drinks per month or binge drinker. T3=tertile 3. T1=tertile 1.324/2989 (11%)108/660 (16%)2·0 (1·3–3·0)15% (8–24%)Current smokers732/2994 (24%)207/662 (31%)1·4 (1·1–2·0)9% (4–20%)Psychosocial stress440/2987 (15%)124/654 (19%)1·2 (0·9–1·7)3% (1–16%)Data are n/N (%), unless otherwise indicated. Multivariable model adjusted for age, sex and region.* More than 30 drinks per month or binge drinker. T3=tertile 3. T1=tertile 1. Open table in a new tab Data are n/N (%), unless otherwise indicated. Multivariable model adjusted for age, sex and region. Population-based mass strategies to reduce consumption of salt, calories, alcohol, and tobacco by improving education and the environment will complement high-risk strategies of identifying those at risk of haemorrhagic (and ischaemic) stroke, thus empowering these individuals to improve their lifestyle behaviours and, if necessary, lower their mean blood pressure and blood pressure variability with appropriate doses of antihypertensive drugs.7Rose G Strategy of prevention: lessons from cardiovascular disease.Br Med J. 1981; 282: 1847-1851Crossref PubMed Scopus (800) Google Scholar, 8Hankey GJ Nutrition and the risk of stroke.Lancet Neurol. 2012; 11: 66-81Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 9Law MR Morris JK Wald NJ Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.BMJ. 2009; 338: b1665Crossref PubMed Scopus (2008) Google Scholar, 10Webb AJS Fischer U Mehta Z Rothwell PM Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis.Lancet. 2010; 375: 906-915Summary Full Text Full Text PDF PubMed Scopus (563) Google Scholar I declare that I have no conflicts of interest. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the Global Burden of Disease Study 2010Although age-standardised mortality rates for ischaemic and haemorrhagic stroke have decreased in the past two decades, the absolute number of people who have these stroke types annually, and the number with related deaths and DALYs lost, is increasing, with most of the burden in low-income and middle-income countries. Further study is needed in these countries to identify which subgroups of the population are at greatest risk and who could be targeted for preventive efforts. Full-Text PDF Open Access

The aim of this study was to retrospectively assess short-term neurological outcomes in pediatric stroke with regard to patient characteristics. Children aged 28 days-18 years with arterial ischemic stroke (AIS), cerebral sinovenous thrombosis (CSVT), and hemorrhagic stroke (HS) between 2007 and 2013 were evaluated. Neurological findings in the first 3 months were accepted as short-term prognosis, and modified Rankin scale was used. A total of 33 patients (62%) with AIS, 12 (23%) with HS, and eight (15%) with CSVT were included. Moya moya syndrome was the most common new diagnosis in AIS. Stroke recurred in five (15%); and one AIS patient with posterior circulation infarct died (3%). Prognosis in AIS was favorable for 20 patients (61%) and poor for 13 patients (39%). Forty-two percent of HS were of vascular origin. Seven patients (70%) with HS had good prognosis and three (30%) had poor prognosis with no death. Homocysteine-related hypercoagulability was most frequently noted in the etiology of CSVT. Synchronous systemic thrombosis was observed in three CSVT patients (37.5%) and death occurred in two (25%). Prognosis was evaluated as favorable for three CSVT patients (37.5%) and poor for five (62.5%). For thrombophilia, thrombosis panel was performed fully in 83% of AIS and CSVT patients. Pediatric stroke is associated with a poor prognosis in a substantial number of patients in the short term, with CSVT having the worst prognosis. Detailed patient characteristics are listed not only for ischemic but also for hemorrhagic stroke; and a full thrombosis panel was achieved for most ischemic stroke patients.

Objective:Neurocognitive deficits commonly occur following pediatric stroke and can impact many neuropsychological domains. Despite awareness of these deleterious effects, neurocognitive outcome after pediatric stroke, especially hemorrhagic stroke, is understudied. This clinical study aimed to elucidate the impact of eight factors identified in the scientific literature as possible predictors of neurocognitive outcome following pediatric stroke: age at stroke, stroke type (i.e., ischemic vs. hemorrhagic), lesion size, lesion location (i.e., brain region, structures impacted, and laterality), time since stroke, neurologic severity, seizures post-stroke, and socioeconomic status.Participants and Methods:Ninety-two patients, ages six to 25 and with a history of pediatric stroke, chose to participate in the study and were administered standardized neuropsychological tests assessing verbal reasoning, abstract reasoning, working memory, processing speed, attention, learning ability, long-term memory, and visuomotor integration. A standardized parent questionnaire provided an estimate of executive functioning. Statistical analyses included spline regressions to examine the impact of age at stroke and lesion size, further divided by stroke type; a series of one-way analysis of variance to examine differences in variables with three levels; Welch’s t-tests to examine dichotomous variables; and simple linear regressions for continuous variables.Results:Lesion size, stroke type, age at stroke, and socioeconomic status were identified as predictors of neurocognitive outcome in our sample. Large lesions were associated with worse neurocognitive outcomes compared to small to medium lesions across neurocognitive domains. Exploratory spline regressions suggested that ischemic stroke was associated with worse neurocognitive outcomes than hemorrhagic stroke. Based on patterns shown in graphs, age at stroke appeared to have an impact on outcome depending on the neurocognitive domain and stroke type, with U-shaped trends suggesting worse outcome across most domains when stroke occurred at approximately 5 to 10 years of age. Socioeconomic status positively predicted outcomes across most neurocognitive domains. Participants with seizures had more severe executive functioning impairments than youth without seizures. Youth with combined cortical-subcortical lesions scored lower on abstract reasoning than youth with cortical and youth with subcortical lesions, and lower on attention than youth with cortical lesions. Neurologic severity predicted scores on abstract reasoning, attention, processing speed, and visuomotor integration, depending on stroke type. There was no evidence of differences on outcome measures based on time since stroke, lesion laterality, or lesion region defined as supra-versus infratentorial.Conclusions:The current study contributed to the scientific literature by identifying lesion size, stroke type, age at stroke, and socioeconomic status as predictors of neurocognitive outcome following pediatric stroke. Future research should examine other possible predictors of neurocognitive outcome that remain unexplored. Multisite collaborations would provide larger sample sizes and allow teams to build models with better statistical power and more predictors. Enhancing understanding of neurocognitive outcomes following pediatric stroke is a first step towards improving appraisals of prognosis.Findings are clinically applicable as they provide professionals with information that can help assess individual expected patterns of recovery and thus refer patients to appropriate support services.

Paediatric stroke in the northern Spanish region of Aragon: incidence, clinical characteristics, and outcomes

An Update on Neurocritical Care for the Patient With Kidney Disease

Stroke has been reported in observational series as a frequent complication of coronavirus disease 2019, but more information is needed regarding stroke prevalence and outcomes. We explored the prevalence and outcomes of acute stroke in an international cohort of patients with coronavirus disease 2019 who required ICU admission. Retrospective analysis of prospectively collected database. A registry of coronavirus disease 2019 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with acute stroke during their stay. Patients older than 18 years old with acute coronavirus disease 2019 infection in ICU. None. Of 2,699 patients identified (median age 59 yr; male 65%), 59 (2.2%) experienced acute stroke: 0.7% ischemic, 1.0% hemorrhagic, and 0.5% unspecified type. Systemic anticoagulant use was not associated with any stroke type. The frequency of diabetes, hypertension, and smoking was higher in patients with ischemic stroke than in stroke-free and hemorrhagic stroke patients. Extracorporeal membrane oxygenation support was more common among patients with hemorrhagic (56%) and ischemic stroke (16%) than in those without stroke (10%). Extracorporeal membrane oxygenation patients had higher cumulative 90-day probabilities of hemorrhagic (relative risk = 10.5) and ischemic stroke (relative risk = 1.7) versus nonextracorporeal membrane oxygenation patients. Hemorrhagic stroke increased the hazard of death (hazard ratio = 2.74), but ischemic stroke did not-similar to the effects of these stroke types seen in noncoronavirus disease 2019 ICU patients. In an international registry of ICU patients with coronavirus disease 2019, stroke was infrequent. Hemorrhagic stroke, but not ischemic stroke, was associated with increased mortality. Further, both hemorrhagic stroke and ischemic stroke were associated with traditional vascular risk factors. Extracorporeal membrane oxygenation use was strongly associated with both stroke and death.

Objectives: We aimed to determine temporal patterns of blood–brain barrier (BBB) dysfunction, edema formation and functional recovery in acute stroke. Materials and Methods: Patients of two observational studies on ischemic and hemorrhagic stroke between 2006 and 2019 were analyzed. Blood–brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio. Edema formation was measured on all available imaging scans during hospital stay. Relative edema was defined as the ratio of edema volume to stroke volume. Multivariable regression models were applied to analyze associations and calculate predicted probabilities. Results: Overall, 138 stroke patients, 103 (74.6%) with ischemic stroke and 35 (25.4%) with hemorrhagic stroke, were analyzed. The predicted probability of substantial BBB dysfunction was approximately 46 (37–55) % among patients analyzed on 1 day after symptom onset and declined with increasing time, thereafter reaching 10 (3–29) % on day 30. The maximal extent of edema was lower in ischemic versus hemorrhagic stroke (relative edema: 1.5 [1.2–1.8] vs. 2.6 [1.9–4.5], p = 0.003) and occurred earlier after stroke onset (5.9 [4.6–8.5] days vs. 12.3 [9.7–16.4] days, p = 0.009). BBB dysfunction was associated with increased edema formation (adjusted relative edema: 4.0 [2.8–4.5] vs. 2.3 [1.8–3.0], p = 0.037) and lower chances of functional recovery (20/48 [41.7%] vs. 51/90 [56.7%], adjusted Odds Ratio: 0.37 [0.16–0.88], p = 0.025) in both ischemic and hemorrhagic stroke patients. Conclusions: BBB dysfunction frequently occurred in acute ischemic and hemorrhagic stroke and was associated with secondary injury and worse clinical outcomes. Future studies should evaluate BBB dysfunction as a potential therapeutic target using advanced imaging techniques early after stroke onset. Edema formation was aggravated and prolonged in hemorrhagic versus ischemic stroke.

Pediatric stroke and epileptic syndrome in Ukrainian patients

Risk factors for pediatric ischemic stroke and intracranial hemorrhage: A national electronic health record based study

The cost of pediatric stroke care has received little attention, but the available data suggest it is expensive. To determine the cost of acute stroke, we analyzed a US national database. Method- We used the Kids' Inpatient Database (KID2003) to determine the hospital-based costs of acute stroke in children ages 3 months to 20 years. Discharges were selected if the first diagnostic position contained an International Classification of Diseases, 9th Revision code pertaining to ischemic or hemorrhagic stroke. We examined the relationship between cost and stroke type by adjusting for variables that predict the cost of adult stroke. There were 2224 pediatric cases, after statistical weighting, discharged with a diagnosis of hemorrhagic or ischemic stroke in KID2003. The estimated cost of acute pediatric stroke in the United States was $42 million in 2003. For the entire cohort, the mean cost of acute hospital care was $20 927 per discharge. The mean cost for ischemic stroke was $15 003, for intracerebral hemorrhage $24 117, and for subarachnoid hemorrhage $31 653. Stroke diagnosis, length of stay, hospital ownership, rural/urban teaching status, US geographical region, and discharge disposition were significantly associated with cost. Cost remained significantly associated with stroke diagnosis after adjusting for other predictors in the final multivariable regression model. Pediatric stroke is expensive, and the lifetime cost of care is likely greater for a child than an adult. The cost to the family and the larger society underscore the importance of pediatric stroke treatment and prevention.

Introduction: The time course and risk of hemorrhagic and ischemic stroke following left ventricular assist device (LVAD) placement is not well described. Hypothesis: Ischemic and hemorrhagic stroke are major causes of mortality following LVAD placement. Methods: Prospectively collected data of Heartmate II (N=335) and Heartware (N=70) LVAD patients from a single center were reviewed from 10/21/2004-5/19/2015. Patients were followed until transplant or death. Predictors of ischemic and hemorrhagic stroke (ICH, SAH, SDH) occurring during hospitalization for LVAD placement (early stroke) or in follow-up (late stroke) were assessed using Chi-squared or Mann-Whitney U tests. The association of stroke and mortality was assessed using multivariable logistic regression analysis. Results: Of 405 patients, stroke occurred in 69 (17%). Early ischemic and hemorrhagic stroke occurred in 18 (4.4%) and 11 (2.7%) patients, respectively. Late ischemic and hemorrhagic stroke occurred in 25 (6.2%) and 29 (7.2%) patients, respectively and 11 (3%) had more than one stroke. ICH was the most common type of hemorrhagic stroke (N=23). History of implanted cardioverter defibrillator, tobacco use, poor NYHA class and hypertension post-LVAD significantly predicted ischemic stroke, while history of hypertension and arrhythmia predicted hemorrhagic stroke (all P<0.05). Stroke was the leading primary cause of death in 17% of LVAD patients (second only to multi-system organ failure [21%]). Most deaths were related to late ischemic stroke (N=9/150, 6%), or late hemorrhagic stroke (N=15/150, 10%), while only 2 (1%) died from early stroke. After adjusting for age, NYHA class, and LVAD type, late ischemic stroke (adjusted odds ratio [aOR] 8.8, 95% CI 3.3-23.5, P<0.0001) and late hemorrhagic stroke (aOR 9.7, 95% CI 4.0-23.4, P<0.0001) predicted death, while early ischemic or hemorrhagic stroke did not. Conclusions: Stroke is a leading cause of death in LVAD patients. Late ischemic and hemorrhagic stroke have a greater impact on mortality than early stroke. Management of risk factors, such as hypertension post LVAD, may reduce stroke and mortality rates.

BackgroundEven though stroke is rare in children, it is associated with serious or life-threatening consequences. Despite its rarity, the occurrence of stroke in children has age-related differences in risk factors, etiopathogenesis, and clinical presentations. Unlike adults, who have arteriosclerosis as the major cause of stroke, risk factors for pediatric strokes are multiple, including cardiac disorders, infection, prothrombotic disorders, moyamoya disease, moyamoya syndrome, and others. The goal of the current study was to compare the characteristics, clinical features, etiology, subtypes, and workup of pediatric and adult strokes.MethodsThis was a hospital-based observational study conducted on 222 participants. All patients underwent a full clinical and neurological examination, full laboratory study, cardiac evaluation, and neuroimaging; CT scan, MRI, MRA, MRV, carotid duplex, and transcranial Doppler (TCD). Ischemic stroke (IS) etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, the "proposed classification for subtypes of arterial ischemic stroke in children," and the Oxfordshire Community Stroke Project (OCSP). Stroke severity was determined by the National Institutes of Health Stroke Scale (NIHSS) and PedNIHSS on admission.ResultsThe proportion of pediatric ischemic strokes in the current study was 63.4 percent, while hemorrhagic strokes were 36.5%. The majority of the adult patients had ischemic strokes (84.1%), while hemorrhagic strokes were noted in 15.8% of the patients. According to the original TOAST classification, in the current study, the etiology of pediatric IS was other determined causes in 63.6%, undetermined etiology in 27.2%, and cardioembolic in 9.0%. For the adult group, the major stroke subtypes were large artery disease, small vessel disease, cardioembolic, other determined causes, and undetermined etiology at 49.6%, 28.6%, 6.9%, 0.6%, and 12.5%, respectively.ConclusionsThere is a greater etiological role for non-atherosclerotic arteriopathies, coagulopathies, and hematological disorders in pediatric stroke, while adults have more atherothrombotic causes. The co-existence of multiple risk factors in pediatric ischemic stroke is noticed. Thrombophilia evaluation is helpful in every case of childhood stroke. Children who have had a stroke should undergo vascular imaging as soon as possible. Imaging modalities include TCD and Doppler ultrasound, CT, MRI, MRA, and MRV, and cerebral angiography.