Acute Arterial Ischemic Stroke Research Articles

Endovascular Treatment for Cerebral Venous Thrombosis: Applying Lessons Learned from Clinical Trials of Endovascular Treatment in Acute Arterial Ischemic Stroke.

Cerebral venous thrombosis (CVT) is a rare but severely disabling form of stroke. Acute treatment mainly consists of medical management, since there is no robust evidence suggesting the benefit of endovascular treatment for CVT. Given the relative lack of data to guide acute treatment decision-making, CVT treatment decisions are mostly made on a case-by-case basis. In some ways, the current status quo of endovascular treatment for CVT resembles the state of endovascular treatment for acute ischemic stroke before the wave of major positive large vessel occlusion endovascular treatment trials in 2015. The current state of evidence with regard to endovascular CVT treatment is summarized, parallels to acute ischemic stroke are drawn, and it is discussed how the lessons learned from the evolution of acute ischemic stroke endovascular treatment (EVT) trials could be applied to designing a trial of endovascular treatment for CVT. The review ends by outlining possible scenarios for the future of endovascular CVT treatment. CVT is a serious disease, affecting young patients and their families, and harbors a considerable social and economic burden. Working toward high-level evidence for the best possible treatment strategy and exploring a possible role for EVT to improve outcomes in CVT needs to remain a high priority in stroke research.

Health Inequity and Time From Pediatric Stroke Onset to Arrival.

Time from stroke onset to hospital arrival determines treatment and impacts outcome. Structural, socioeconomic, and environmental factors are associated with health inequity and onset-to-arrival in adult stroke. We aimed to assess the association between health inequity and onset-to-arrival in a pediatric comprehensive stroke center. A retrospective observational study was conducted on a consecutive cohort of children (>28 days-18 years) diagnosed with acute arterial ischemic stroke (AIS) between 2004 and 2019. Neighborhood-level material deprivation was derived from residential postal codes and used as a proxy measure for health inequity. Patients were stratified by level of neighborhood-level material deprivation, and onset-to-arrival was categorized into 3 groups: <6, 6 to 24, and >24 hours. Association between neighborhood-level material deprivation and onset-to-arrival was assessed in multivariable ordinal logistic regression analyses adjusting for sociodemographic and clinical factors. Two hundred and twenty-nine children were included (61% male; median age [interquartile range] at stroke diagnosis 5.8-years [1.1-11.3]). Over the 16-year study period, there was an increase in proportion of children diagnosed with AIS living in the most deprived neighborhoods and arriving at the emergency room within 6 hours (P=0.01). Among Asian patients, a higher proportion lived in the most deprived neighborhoods (P=0.02) and level of material deprivation was associated with AIS risk factors (P=0.001). Our study suggests an increase in pediatric stroke in deprived neighborhoods and certain communities, and earlier arrival times to the emergency room over time. However, whether these changes are due to an increase in incidence of childhood AIS or increased awareness and diagnosis is yet to be determined. The association between AIS risk factors and material deprivation highlights the intersectionality of clinical factors and social determinants of health. Finally, whether material deprivation impacts onset-to-arrival is likely complex and requires further examination.

Development of Collateral Vessels after Anterior Circulation Large Vessel Occlusion in Pediatric Arterial Ischemic Stroke Relates to Stroke Etiology: A Longitudinal Study.

The characteristics of large vessel occlusion (LVO) in the acute phase of pediatric arterial ischemic stroke and their natural history according to stroke etiology are poorly explored. This studied aimed at describing the prevalence and the radiological evolution of LVO in pediatric AIS. This single-center retrospective study included consecutive non-neonate children with acute arterial ischemic stroke, intracranial proximal LVO in the anterior circulation (MCA, anterior cerebral artery, and/or ICA), and clinical and imaging follow-up for at least 18 months, during a 9-year period. Intracranial LVO was observed in 24.8% of patients with anterior circulation arterial ischemic stroke and adequate follow-up (n = 26/105), with a median age of 4.2 years (IQR 0.8-9), sex ratio 1.16. The main stroke etiology associated with LVO was unilateral focal cerebral arteriopathy (n = 12, 46%). During follow-up, a specific pattern of unilateral poststroke anastomotic bridge was observed in 8/26 patients, with the poststroke development of nonperforating collaterals forming a bridge in bypass of the LVO site with visible distal flow, within a median delay of 11 months. The development of unilateral poststroke anastomotic bridge was only observed in patients with unilateral focal cerebral arteriopathy. No patient with this pattern experienced stroke recurrence or further progressive vascular modifications. After stroke, the development of unilateral poststroke anastomotic bridge is specifically observed in children with focal cerebral arteriopathy, appearing in the first year after stroke. This clinical-radiologic pattern was not associated with stroke recurrence or arterial worsening, differentiating it from progressive intracranial arteriopathy, such as Moyamoya angiopathy.

Abstract TMP9: Flair Vascular Hyperintensities as Imaging Biomarker in Pediatric Arterial Ischemic Stroke

Background: FLAIR vascular hyperintensities (FVH) are high signal intensities on MRI resulting from sluggish flow through collateral vessels in patients with acute arterial ischemic stroke (AIS). Data from adults suggest they may be a marker of penumbra. In this first investigation of FVH in children, I measured the prevalence and identified risk factors for FVH in pediatric patients with AIS. Methods: Retrospective review of patients prospectively enrolled in the CHOP Stroke Registry from 2006-2022. Patients with AIS age 29 days to 18 years with MRI within 72 hours of last known well were included. Children with pre-existing strokes, vasculopathy, prior brain surgery, radiation, or vascular compression from intracranial mass were excluded. MRIs were assessed by a blinded reviewer and adjudicated by a neuroradiologist for presence of LVO, FVH score, modASPECTS score, and AIS lesion volume. Clinical data were abstracted from chart review. Independent sample t-test compared FVH score and LVO presence. Pearson's correlation assessed the relationship between total FVH score and age, stroke size, modASPECTS, and pedNIHSS scores. Multivariable logistic regression evaluated predictors of significant FVH (score &gt;= 3) and included time to MRI, large vessel occlusion, modASPECTS, pedNIHSS, stroke size, and age as independent variables. Results: 83 patients met inclusion criteria. Median time to MRI was 26 hours (95% CI 26-33). FVH were present in 45 patients (54%). Mean FVH score was higher in patients with LVO (5.22 ± 0.64) compared to those without (1.21 ± 0.24; p = 0.00). There was a positive correlation between total FVH score and age (p &lt; 0.05), stroke size (p &lt; 0.0001), modASPECTS (p &lt; 0.0000), and pedNIHSS (p &lt; 0.0002). In the multivariate logistic regression, only older age (OR 1.50, 95% CI 1.12-2.01, p &lt; 0.006) and presence of LVO (OR 0.002, 95% CI 4.85x10 -5 -0.08, p&lt;0.001) were associated with significantly increased odds of high FVH burden. Conclusions: FVH are prevalent in children with AIS, with higher burden in older children. Similar to adults, large vessel occlusion and larger infarct size are associated with higher FVH burden. Further study is needed on whether FVH could be used to identify patients who would benefit from reperfusion therapies.

Low value of inherited thrombophilia testing among patients with stroke or transient ischemic attack: A three-year retrospective study

Background/PurposeInherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and rarely changes clinical management. We evaluated ordering patterns and results of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism. MethodsWe retrospectively analyzed patients admitted for acute ischemic stroke or TIA between January 1st, 2019 and December 31st, 2021 at Thomas Jefferson University Hospitals in Philadelphia, PA and who underwent inherited thrombophilia testing during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management. ResultsAmong 2108 patients admitted for acute ischemic stroke or TIA (including branch and central retinal artery occlusions) during the study period, the study included 249 patients (median age 49.0 years, 50.2% female) who underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 42.2% of patients had at least one abnormal test, and among the 1035 tests ordered, 14.3% resulted abnormal. However, 28% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. There was no significant difference in the likelihood of a positive test among patients without stroke risk factors vs those with risk factors (47.1% vs 40.9%, P = .428), nor any significant difference between those under vs over age 50 years (45.7% vs 38.3%, P = .237). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $468,588 USD. ConclusionsInherited thrombophilia testing in the hospital immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of likely false positive results and was expensive. Positive results did not change clinical management in a single case.

Reader Response: Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis.

Stefanou et al.1 conducted the first meta-analysis to estimate the prevalence of acute arterial ischemic stroke (AIS) after COVID-19 vaccination. Their study draws the key conclusion that the prevalence of AIS after COVID-19 vaccination was comparable with the prevalence of AIS in the general population. However, Table 3 shows that the authors derived the AIS prevalence per 100,000 COVID-19 vaccinations, which was 4.7; this rate is significantly lower than the age-standardized global AIS prevalence rate (951-1,038) and incidence rate (95–98) per 100,000 individuals per year in the general population. This seems to suggest the possible association of COVID-19 vaccination with lower risk of AIS.

Editors' Note: Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis.

Dr. Stefanou et al. analyzed the risk of acute ischemic stroke (AIS) after COVID-19 vaccination and its potential association with thrombotic-thrombocytopenia syndrome (TTS) in a systematic review and meta-analysis of 2 randomized-controlled trials (RCTs), 3 cohort studies, and 11 registry-based studies. They found 17,481 AIS cases among 782,989,363 COVID-19 vaccinations, giving a pooled proportion of postvaccination AIS of 4.7 cases per 100,000 vaccinations, with no difference observed between mRNA-based and adenovirus-based vaccinations. The pooled proportion of TTS in AIS cases was 3.1%. In response, Dr. Du notes that the rate of AIS cases was lower than the age-standardized global AIS prevalence and incidence rates per 100,000 individuals per year, suggesting that the vaccinations may be associated with a lower risk of AIS. In this regard, Dr. Du cites a previous study that found a significant association between COVID-19 vaccination and lower risks of myocardial infarction and ischemic stroke. Responding to these comments, the authors caution that their crude estimate of new AIS events per 100,000 vaccination, without age standardization or annualization, was not directly comparable with age-standardized AIS estimates per 100,000 individuals per year in the general population. These exchange raises demonstrate relevant complexities when seeking to compare the risk of postvaccination AIS with the “background” risk in the general population while motivating additional studies to investigate whether COVID-19 vaccination might reduce AIS risk at a population level. Dr. Stefanou et al. analyzed the risk of acute ischemic stroke (AIS) after COVID-19 vaccination and its potential association with thrombotic-thrombocytopenia syndrome (TTS) in a systematic review and meta-analysis of 2 randomized-controlled trials (RCTs), 3 cohort studies, and 11 registry-based studies. They found 17,481 AIS cases among 782,989,363 COVID-19 vaccinations, giving a pooled proportion of postvaccination AIS of 4.7 cases per 100,000 vaccinations, with no difference observed between mRNA-based and adenovirus-based vaccinations. The pooled proportion of TTS in AIS cases was 3.1%. In response, Dr. Du notes that the rate of AIS cases was lower than the age-standardized global AIS prevalence and incidence rates per 100,000 individuals per year, suggesting that the vaccinations may be associated with a lower risk of AIS. In this regard, Dr. Du cites a previous study that found a significant association between COVID-19 vaccination and lower risks of myocardial infarction and ischemic stroke. Responding to these comments, the authors caution that their crude estimate of new AIS events per 100,000 vaccination, without age standardization or annualization, was not directly comparable with age-standardized AIS estimates per 100,000 individuals per year in the general population. These exchange raises demonstrate relevant complexities when seeking to compare the risk of postvaccination AIS with the “background” risk in the general population while motivating additional studies to investigate whether COVID-19 vaccination might reduce AIS risk at a population level.

Author Response: Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis.

We would like to thank Drs. Du, Li, and Zhao for the comment on our research.1 We wish to highlight some methodological nuances and elucidate why the estimated arterial ischemic stroke (AIS) prevalence after COVID-19 vaccination (4.7/100,000 COVID-19 vaccinations) was deemed comparable with that in the general population.

Evaluation of risk factors, functionalities, and quality of life in patients with pediatric acute arterial ischemic stroke.

This study aimed to evaluate the etiology and prognosis of patients followed up for pediatric acute arterial ischemic stroke. The clinical characteristics and etiology of patients aged 1 month-18 years who had acute arterial ischemic stroke between January 2010 and December 2020 were retrospectively evaluated. At last follow-up, the patients` functionality (Barthel Index, Functional Independence Measure), quality of life (SF-36 questionnaire), and motor outcomes (Gross Motor Function Classification System) were recorded prospectively/crosssectionally. Forty children (25 boys) with a median current age of 112.5 months (range: 3.6-294) were included in the study. The most frequent etiology was prothrombotic disorders, and the most important factor associated with long-term mortality was valvular heart disease. Of the 27 (67.5%) surviving patients, 29.6% had positive motor outcomes and 29.6% were independent according to the Barthel Index. In terms of quality of life, SF-36 scores were highest in the pain scale and lowest in emotional role difficulty. Determining the etiology and evaluating prognosis are important to plan effective treatment and rehabilitation for pediatric acute arterial ischemic stroke.

Intravenous Thrombolytics in the Treatment of Acute Ischemic Stroke

To review the current evidence and ongoing clinical trials evaluating the efficacy and safety of tenecteplase (TNK), an alternative tissue plasminogen activator (tPA), in the acute management of arterial ischemic stroke (AIS). To date, alteplase is the only tPA approved by the United States FDA for use in AIS. There have been multiple phase two and three trials investigating the safety and efficacy of TNK in AIS. In patients with AIS due to large vessel occlusion, one randomized controlled trial demonstrated superiority of TNK for vessel recanalization rates and long-term functional outcomes when compared to alteplase. A meta-analysis of all phase two and three trials evaluating TNK in AIS concluded that TNK has a comparable safety and efficacy profile to alteplase. The results of these trials prompted new recommendations in the Acute Stroke Guideline published by the AHA suggesting it may be reasonable to use as an alternative to alteplase. Furthermore, recent real-world data has also reported decreased door-to-needle time with TNK utilization. In patients with AIS, use of a thrombolytic agent is standard of care and has been shown to reduce neurological disability and improve functional outcome. Randomized controlled trials have demonstrated that TNK is non-inferior to alteplase from a clinical outcome and safety standpoint. The existing data evaluating the efficacy of TNK compared to alteplase in acute AIS within 4.5h from symptom onset showed no significant difference between these two agents with regard to functional outcome at 90days but improved median time to treatment and large vessel recanalization in TNK-treated patients. The results from ongoing TNK trials in larger patient cohorts and in wake-up stroke populations will be instrumental to the wide-scale utilization of TNK in acute AIS management.

Clinical and Imaging Clues of Arteriopathy-Related Pediatric Arterial Ischemic Stroke: A Single Center Experience.

Arteriopathy is a common etiology for childhood arterial ischemic stroke (AIS). In this study, we aimed to address clinical, demographic, and neuroimaging characteristics and the reversibility of vasculopathy in patients with childhood stroke due to arteriopathy by classifying them according to Childhood AIS Standardized Classification and Diagnostic Evaluation (CASCADE) criteria. We included 15 patients with AIS due to arteriopathy presented between 2013 and 2018. All patients were diagnosed and followed up using magnetic resonance imaging (MRI) studies. All acute AIS patients were classified by acute CASCADE criteria (1-4). Moreover, each group was categorized according to the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate courses. In the study population, CASCADE 2 patients were the most common group, and basal ganglia involvement was the most common involvement in CASCADE 2 patients. Of CASCADE 2 patients, 71.4% received steroids, which was compatible with a favorable outcome. In the study, trauma was present in 33.3% of patients, 60% of which was related to CASCADE 4. In the control visit on month 24, there were neuromotor sequelae of 60%, including hemiparesis, facial paralysis, and decreased fine motor skills; furthermore, the recurrence rate was 20%. We strongly emphasize that arteriopathy should be kept in mind in school-age children presenting with hemiparesis and headache. Moyamoya disease must be considered in the differential diagnosis with anterior circulation involvement, while focal cerebral arteriopathy (FCA) in patients with basal ganglia involvement was detected on MRI and dissection in the patients with a history of head-neck injury. We think that steroids have positive influences on neurologic prognosis in patients with FCA.

Spotlight on the October 4 Issue

![Graphic][1]</img>#### Notable in Neurology This Week This issue features an article that assesses the feasibility, acceptability, and perceived usefulness of a decision aid for goals-of-care communication with surrogate decision-makers for critically ill patients with severe acute brain injury; another investigates the effects of New York State's universal newborn screening for spinal muscular atrophy 3 years after being added to the Recommended Uniform Screening Panel. A featured research article examines the effects of trauma and discrimination on migraine-associated disability in a sample of sexual and/or gender minority adults. ### Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis Acute arterial ischemic stroke (AIS) comprises a rare adverse event … [1]: /embed/inline-graphic-1.gif

Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis.

Acute arterial ischemic stroke (AIS) has been reported as a rare adverse event following coronavirus disease 2019 (COVID-19) vaccination with messenger RNA (mRNA) or viral vector vaccines. However, data are sparse regarding the risk of postvaccination AIS and its potential association with thrombotic-thrombocytopenia syndrome (TTS). A systematic review and meta-analysis of randomized controlled clinical trials (RCTs), pharmacovigilance registries, registry-based studies, observational cohorts, and case-series was performed with the aim to calculate the following: (1) the pooled proportion of patients presenting with AIS following COVID-19 vaccination; (2) the prevalence of AIS after mRNA and vector-based vaccination; and (3) the proportion of TTS among postvaccination AIS cases. Patient characteristics were assessed as secondary outcomes. Two RCTs, 3 cohort studies, and 11 registry-based studies comprising 17,481 AIS cases among 782,989,363 COVID-19 vaccinations were included in the meta-analysis. The pooled proportion of AIS following exposure to any COVID-19 vaccine type was 4.7 cases per 100,000 vaccinations (95% CI 2.2-8.1; I 2 = 99.9%). The pooled proportion of AIS following mRNA vaccination (9.2 cases per 100,000 vaccinations; 95% CI 2.5-19.3; I 2 = 99.9%) did not differ compared with adenovirus-based vaccination (2.9 cases per 100,000 vaccinations; 95% CI 0.3-7.8; I 2 = 99.9%). No differences regarding demographics were disclosed between patients with AIS following mRNA-based or vector-based vaccination. The pooled proportion of TTS among postvaccination AIS cases was 3.1% (95% CI 0.7%-7.2%; I 2 = 78.8%). The pooled proportion of AIS following COVID-19 vaccination is comparable with the prevalence of AIS in the general population and much lower than the AIS prevalence among severe acute respiratory syndrome coronavirus 2-infected patients. TTS is very uncommonly reported in patients with AIS following COVID-19 vaccination.

Study of Transesophageal Echocardiography in Young Patients with Cryptogenic Stroke: Prevalence of Patent Foramen Ovale and Interpretation of the RoPE Score.

Cryptogenic stroke (CS) is considered to be the most common stroke subtype in young patients. The Risk of Paradoxical Embolism (RoPE) score is a tool that stratifies patients with CS according to the probability of patent foramen ovale (PFO). The aim of this retrospective study is to determine the prevalence of PFO in young patients with transesophageal echocardi- ography (TEE) and to evaluate the role of RoPE score in PFO-related strokes. The medical records of patients with acute arterial ischemic stroke, who underwent TEE between 2016 and 2020, were reviewed. Patients aged 18-55 years were included in the study. Presence of PFO, PFO characteristics, presence of atrial septal aneurysm (ASA) were detected by examining the image records of the patients from the archive system. RoPE score was calculated for all patients as determined in the literature. Totally, 50 CS patients were included in the study (mean age: 39.6±9.4 years). PFO was detected in 19 (38%) patients and it was the most common cardiac abnormality in CS patients. ASA was detected in 7 (14%) patients. The mean RoPE score in patients with PFO was higher than patients without PFO, although it did not reach statistical significance (7.68±1.1 versus 6.77±1.9 P = .07). Eighteen of 19 patients with PFO had a RoPE score ≥7. In our study, PFO prevalence in the CS patients was higher than normal popula- tion. In patients with cryptogenic stroke, the RoPE score can help determine the probability of PFO related stroke and which patients should undergo TEE.

International Prevalence and Mechanisms of SARS-CoV-2 in Childhood Arterial Ischemic Stroke During the COVID-19 Pandemic.

Background:Data from the early pandemic revealed that 0.62% of children hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had an acute arterial ischemic stroke (AIS). In a larger cohort from June 2020 to December 2020, we sought to determine whether our initial point estimate was stable as the pandemic continued and to understand radiographic and laboratory data that may clarify mechanisms of pediatric AIS in the setting of SARS-CoV-2.Methods:We surveyed international sites with pediatric stroke expertise to determine numbers of hospitalized SARS-CoV-2 patients <18 years, numbers of incident AIS cases among children (29 days to <18 years), frequency of SARS-CoV-2 testing for children with AIS, and numbers of childhood AIS cases positive for SARS-CoV-2 June 1 to December 31, 2020. Two stroke neurologists with 1 neuroradiologist determined whether SARS-CoV-2 was the main stroke risk factor, contributory, or incidental.Results:Sixty-one centers from 21 countries provided AIS data. Forty-eight centers (78.7%) provided SARS-CoV-2 hospitalization data. SARS-CoV-2 testing was performed in 335/373 acute AIS cases (89.8%) compared with 99/166 (59.6%) in March to May 2020, P<0.0001. Twenty-three of 335 AIS cases tested (6.9%) were positive for SARS-CoV-2 compared with 6/99 tested (6.1%) in March to May 2020, P=0.78. Of the 22 of 23 AIS cases with SARS-CoV-2 in whom we could collect additional data, SARS-CoV-2 was the main stroke risk factor in 6 (3 with arteritis/vasculitis, 3 with focal cerebral arteriopathy), a contributory factor in 13, and incidental in 3. Elevated inflammatory markers were common, occurring in 17 (77.3%). From centers with SARS-CoV-2 hospitalization data, of 7231 pediatric patients hospitalized with SARS-CoV-2, 23 had AIS (0.32%) compared with 6/971 (0.62%) from March to May 2020, P=0.14.Conclusions:The risk of AIS among children hospitalized with SARS-CoV-2 appeared stable compared with our earlier estimate. Among children in whom SARS-CoV-2 was considered the main stroke risk factor, inflammatory arteriopathies were the stroke mechanism.

Double Trouble: Stroke in a Child with Down's Syndrome

AbstractDown's syndrome (trisomy 21) is well recognized to be associated with several autoimmune conditions such as hypothyroidism, celiac disease, and diabetes mellitus. Antiphospholipid syndrome (APS), an immune disorder, can cause a stroke due to the prothrombotic state. APS is associated with several autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, and systemic vasculitis, as well as Down's syndrome. Down's syndrome is linked to several other risk factors for stroke including congenital heart disease, moyamoya disease, and arterial dissection. We present the case of a 3-year-old girl child patient with Down's syndrome, who presented with an acute arterial ischemic stroke secondary to carotid artery dissection and subsequently was also confirmed to have APS. We review the literature on Down's syndrome and APS, the proposed pathophysiology, and management strategies. We present a case of a 3-year-old girl with Down's syndrome and who presented with stroke, review previously published cases, and discuss the conditions and their management. Autoimmune conditions, such as antiphospholipid syndrome, are more common in individuals with Down's syndrome, and as such should be investigated when these children present with symptoms suggestive of stroke.

Abstract 63: Recanalization Treatments In Pediatric Stroke: Safety And Efficacy Data Issued From The French KidClot Study

Background: Safety and efficacy of recanalization treatments, i.e. intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT), have to be refined in pediatric stroke. Methods: The French KIDCLOT multisourcing nationwide retrospective study (NCT03887143) collected data of consecutive children aged &gt;28 days and &lt;18 years old with acute arterial ischemic stroke who had a recanalization treatment, during a 41 month-period. Results: 68 patients, 44 boys (64.7%), median age at stroke onset 11.5 years old, were included. Pre-stroke mRS was 0 for 89.7%. Main stroke etiologies were cardio-embolic (30.9%), focal cerebral arteriopathy (FCA, 25%), cervical (carotid/vertebral) arteriopathy (13.2%), and thrombotic (11.8%). 70 pediatric procedures were recorded: IVT alone (n=31), MT alone (n=23), combined IVT and MT (n=14), and DSA without recanalization treatment (n=4). Median stroke onset to first recanalization treatment delay was shorter in adult stroke units than in pediatric wards (188 vs. 264 minutes respectively, p=0.0087). An early complication was reported for 6 procedures, including two significant intracranial hemorrhages. After MT, cardio-embolic stroke patients achieved good arterial recanalization more frequently than FCA patients (88.9% vs 33.3%). Although high initial severity markers (median NIHSScore=13.5, decreased consciousness in 52.2%, decompressive craniectomy in 17.1%), outcome was relatively good in the 65/68 survivors (median mRS=1 and PSOM=1.2 at 12 month-follow-up). Conclusions: This study provides encouraging safety data despite severe stroke presentations. It suggests potential ways to improve recanalization treatments efficacy in children: reducing management delays in pediatric wards and optimizing etiological orientation since the hyperacute phase, as cardio-embolic strokes seem to display a better recanalization rate profile.

Abstract TMP59: Low Value Of Inherited Thrombophilia Testing Among Patients With Stroke Or Transient Ischemic Attack: A Single-institution Study

Background/Purpose: Inherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and in many cases does not change clinical management. We sought to determine the value of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism. Methods: We retrospectively analyzed a database comprising patients who were admitted for acute ischemic stroke or TIA in 2019 at Thomas Jefferson University Hospitals in Philadelphia, PA and had inherited thrombophilia testing performed during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management. Results: The study included 102 patients (median age 49.0 years, 53.9% female) who presented with acute ischemic stroke or TIA (including branch and central retinal artery occlusions) and underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 406 tests were ordered, among which 14.0% resulted abnormal, and 41.2% of patients had at least one abnormal test. Patients without stroke risk factors were more likely to have an abnormal result (60.0% vs 35.1%, P = .028). However, 40% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. Considering only definitively positive results, there was no significant difference in the likelihood of a positive test in patients with vs without stroke risk factors (32.0% vs 26.0%, P = .557) or those under vs over age 50 years (30.2% vs 24.5%, P = .519). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $182,994 USD. Conclusions: Inpatient inherited thrombophilia testing immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of false positive results and was expensive. Positive results did not change clinical management in a single case.

Stroke in Middle Eastern children with cancer: prevalence and risk factors

ObjectiveTo determine the prevalence and to characterize the different types of strokes in children with cancer at the Children’s Cancer Center of Lebanon (CCCL), in addition to assess the factors and clinical findings leading to stroke in children.Methods We retrospectively reviewed the medical records and brain images (MRIs and CTs) of children admitted to the CCCL and diagnosed with cancer between years 2008 and 2017. Brain images were reviewed for the strokes’ onset, size, location, possible origin, its recurrence and type: intracranial hemorrhage (ICH), acute arterial ischemic stroke, and cerebral sinus venous thrombosis (CSVT) with and without venous infarct. Medical charts of the patients were reviewed for age, sex, their type of cancer, the treatment protocol they followed, and abnormal findings on their laboratory studies and neurological exams.ResultsOut of the 905 charts reviewed, twenty-seven children with variable types of cancer had strokes, with a prevalence of 2.9%. Their median age at cancer diagnosis was 9.4 (4.8-13.7) years and the median age at stroke onset was 10.6 (6.7-15.5) years. The median time between the cancer diagnosis and the stroke episode was 6 months. CSVT cases were the most common (60%) followed by acute arterial ischemic (22%) and hemorrhagic strokes (18%), with CSVT being the latest to occur. We observed that the different types of strokes were related to some types of cancer. Of the children that had acute arterial ischemic stroke in this cohort, 83% had brain tumors, of the children who had CSVT, 87.5% had leukemia, and of the children who had hemorrhagic stroke, 40% had leukemia. Neurological abnormalities were more prevalent in acute arterial ischemic stroke (80%). Patients with CSVT recovered better than those with other types of strokes. Strokes recurred in 60% of ischemic strokes. L-Asparaginase was significantly associated with CSVT.ConclusionsThe prevalence of strokes was 2.9% in children with cancer. We were able to identify factors related to the types of the stroke that occurred in children including the type and location of the cancer the type of treatment received, and stroke recurrence.

Prognostic impact of chronic inflammatory diseases in patients with ST-segmentelevation myocardial infarction

Chronic inflammatory diseases (CID) are common and affect 5 to 7% of the general population. In primary prevention the presence of CID increases the risk of cardiovascular disease (e.g. ST-segment elevation myocardial infarction or STEMI), but the prognosis after the occurrence of STEMI in these patients is poorly studied. The objective of our study is to determine the prognostic impact related to the presence of a MIC on mortality in patients with STEMI. Single-centre cohort including patients managed at the University Hospital of Limoges for STEMI from June 2011 to May 2019 and included in the SCALIM registry. The presence of any MIC defined the CID+ group, compared to other patients (CID-). The primary endpoint was mortality. Secondary endpoints included cardiovascular mortality, recurrent coronary events, new cardiac hospitalizations, occurrence of acute peripheral arterial events and ischemic stroke, and all of those combined. Our study included 1941 patients aged 65 ± 14 years, 75% of whom were men. The prevalence of CID in the SCALIM registry was 4.6% (including 22% rhumatoid arthritis, 19% psoriasis and 16% ankylosing spondylitis) and 40% were on corticosteroid therapy and 20% on biotherapy at STEMI. Over a mean follow-up of 3.4 ± 2.6 years after STEMI, we found no significant difference in mortality in the CID+ and CID- groups respectively (22.5% vs. 15.9% P = 0.14) or in the combined secondary endpoint (29% vs. 49% P = 0.11). Long-term corticosteroid therapy was associated with excess mortality in the CID+ group (39% vs. 12%, P < 0.01). Despite the cardiovascular excess risk described in the literature related to the presence of a MIC, we did not show mortality excess related to these conditions after a STEMI. The mortality risk excess in patients under corticosteroids suggests a multidisciplinary discussion on their management. Further analysis is needed to confirm our results.