Cases Of Arterial Ischemic Stroke Research Articles

Abstract 112: Assessing the Impact of the COVID-19 Pandemic on Childhood Arterial Ischemic Stroke: An Unanticipated Natural Experiment

Introduction: The Vascular effects of Infection in Pediatric Stroke (VIPS II) study aimed to confirm prior findings that viral infection can trigger childhood arterial ischemic stroke (AIS). The COVID-19 pandemic developed midway through VIPS II enrollment, creating an opportunity to assess its impact. Methods: At 22 North American sites, we enrolled 205 children (28 days-18 years) with AIS (12/2016 - 1/2022), collected serum samples up to 7 days post-stroke, and measured clinical infection via parental interview. We defined the COVID-19 pandemic epoch as 1/2020-1/2022. We collected serum samples on 40 stroke-free controls (median [IQR] age 13.2 years [6.4, 16.5]) during the pandemic. We measured SARS-CoV2 spike IgG antibodies (present after vaccination or infection) and nucleocapsid IgG total antibodies (present after infection only; elevated for months). Results: The sites saw 117 AIS cases in 2019 (51 enrolled), 122 (44) in 2020, and 109 (52) in 2021. Comparing the pre-pandemic (N=105) and pandemic (N=100) cohorts, pandemic cases were less likely to report a recent infection (Table). Evidence of SARS-CoV2 infection was seen in 4 (10%) of controls and 26 (25%) of 100 pandemic cases (p=0.065); 10 of the 26 COVID positive cases reported a recent infection, and 7 of the 10 had a clinical diagnosis of COVID. Median (IQR) nucleocapsid IgG titers were 18.8 (12.0, 101) in the positive controls and 50.1 (26.9, 95.3) in the positive cases (p=0.33). Conclusions: The COVID19 pandemic reduced the proportion of childhood AIS cases with preceding infection, likely reflecting decreased infectious exposures while “stay at home” and masking policies were in effect. A quarter of cases in the pandemic era had positive antibodies consistent with prior SARS-CoV2 infection. Like other childhood respiratory viruses, SARS-CoV2 may act as a trigger for childhood AIS, but further investigation is needed to establish a causal role.

Genomic risk scores and oral contraceptive-associated ischemic stroke risk: a call for collaboration

BackgroundOral contraceptives (OCs) are generally safe but vascular risk factors increase OC-associated ischemic stroke risk. We performed a case-control study to evaluate whether a genomic risk score for ischemic stroke modifies OC-associated ischemic stroke risk.MethodsThe Genetics of Early-Onset Stroke study includes 332 premenopausal women (136 arterial ischemic stroke cases and 196 controls) with data on estrogen-containing OC use within 30 days before the index event (for cases) or interview (for controls). Using a previously validated genetic risk score (metaGRS) for ischemic stroke based on 19 polygenic risk scores for stroke and stroke-associated risk factors, we stratified our combined case-control sample into tertiles of genomic risk. We evaluated the association between OC use and ischemic stroke within each tertile. We tested if the association between OC use and ischemic stroke depended on the genomic risk of stroke using logistic regression with an OC use × metaGRS interaction term. These analyses were performed with and without adjustment for smoking, hypertension, diabetes, coronary heart disease, and body mass index.ResultsAfter adjustment for vascular risk factors, the odds ratio of OC use was 3.2 (1.7–6.3) overall and increased from the lower, middle, and upper tertile of genomic risk from 1.6 (0.5–5.4) to 2.5 (0.08–8.2) to 13.7 (3.8–67.3) respectively, and a p-value for interaction of 0.001.ConclusionsOur results suggest that genomic profile may modify the OC-associated ischemic stroke risk. Larger studies are warranted to determine whether a genomic risk score could be clinically useful in reducing OC-associated ischemic stroke.

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.

On three causes of pediatric arterial ischemic stroke

Pediatric arterial ischemic stroke (AIS) has different etiologies compared with adults. Strokes in children are rarer, but not less serious. We discuss three different cases of AIS.

Arterial Ischemic Stroke-Peculiarities of Clinical Presentation and Risk Factors in Indian Children.

There are not enough recent studies on arterial ischemic stroke (AIS) in Indian children. We retrospectively reviewed data on 95 children (69 boys), aged 3 months to 17 years, with AIS. Focal signs were noted in 84 (88%) with hemiparesis in 72 (76%). Diffuse signs were present in 33 (35%) with fever in 22 (23%), altered mental status in 20 (21%), and headache in 12 (13%). Seizures occurred in 29 (31%) children. Arteriopathy was observed in 57 (60%) children with mineralizing lenticulostriate vasculopathy (mLSV) in 22 (23%) being the most common, followed by moyamoya in 14 (15%), arterial dissection in 9 (10%), and focal cerebral arteriopathy (FCA) in 8 (8%). Preceding head/neck trauma was present in 27 (28%) children: 23 had minor head trauma (MHT), 3 neck trauma, and 1 unspecified. Other common risk factors (RFs) were iron deficiency in 10 children, homocysteinemia in 8 children, and tuberculous meningitis in 5 children. Complete or nearly complete recovery occurred in 42 (44%). Nine children developed epilepsy and five cognitive and language disability. Stroke recurrences occurred in nine children. Overall, arteriopathies accounted for majority of the cases of childhood AIS in our study with mLSV and moyamoya being the most frequent. Compared with data from Western countries, FCAs, postvaricella arteriopathy, and arterial dissections were less common. Of the nonarteriopathic RFs, MHT, iron deficiency, homocysteinemia, and neuroinfections were most frequent in our cohort in contrast to cardioembolic diseases and inherited procoagulant conditions, which are common in developed countries.

Cancer and Tumor-Associated Childhood Stroke: Results From the International Pediatric Stroke Study

BackgroundThe prevalence of cancer among children with stroke is unknown. This study sought to evaluate cancer- and tumor-associated childhood ischemic stroke in a multinational pediatric stroke registry. MethodsChildren aged 29 days to less than 19 years with arterial ischemic stroke or cerebral sinovenous thrombosis enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including stroke treatment and recurrence were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests. ResultsCancer or tumor was present in 99 of 2968 children (3.3%) with arterial ischemic stroke and 64 of 596 children (10.7%) with cerebral sinovenous thrombosis. Among children in whom cancer type was identified, 42 of 88 arterial ischemic stroke cases (48%) had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 cerebral sinovenous thrombosis cases (78%) had hematologic malignancies and eight (14%) had brain tumors. Of 54 cancer-associated arterial ischemic stroke cases with a known cause, 34 (63%) were due to arteriopathy and nine (17%) were due to cardioembolism. Of 46 cancer-associated cerebral sinovenous thrombosis cases with a known cause, 41 (89%) were related to chemotherapy-induced or other prothrombotic states. Children with cancer were less likely than children without cancer to receive antithrombotic therapy for arterial ischemic stroke (58% vs 80%, P = 0.007) and anticoagulation for cerebral sinovenous thrombosis (71% vs 87%, P = 0.046). Recurrent arterial ischemic stroke (5% vs 2%, P = 0.04) and cerebral sinovenous thrombosis (5% vs 1%, P = 0.006) were more common among children with cancer. ConclusionsCancer is an important risk factor for incident and recurrent childhood stroke. Stroke prevention strategies for children with cancer are needed.

Mechanical Thrombectomy in Pediatric Stroke: Report of Three New Cases

BackgroundMechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children. MethodsWe report 3 new cases of pediatric stroke treated using mechanical thrombectomy. Two cases of AIS and 1 case of CVT were identified from 2018 pediatric stroke clinic records. ResultsThrombectomy was successful in 1 of the 2 AIS cases and in the CVT case. None of the children were asymptomatic after thrombectomy. One AIS case had good recovery than developed dystonia which responded to treatment; the second AIS case had residual hemiplegia; and the child with CVT had mild school problems. ConclusionsMechanical thrombectomy is being increasingly used for pediatric stroke treatment. This study and recent literature reviews suggest thrombectomy holds promise as a treatment for selected pediatric stroke patients. Questions remain about the safety and efficacy of thrombectomy in children with stroke since large randomized controlled studies are not yet feasible.

Features of Childhood Arterial Ischemic Stroke in China

Objective: The aim of this study was to identify the features and risk factors for arterial ischemic stroke (AIS) in children.Methods: We retrospectively analyzed the initial symptoms, clinical manifestations, risk factors, neuroradiological findings, and treatment data of 75 Chinese children aged between 1 month and 14 years (median 5.7 years) who were diagnosed with AIS in our hospital between 2013 and 2018.Results: Among these 75 cases of childhood AIS, 53 patients (70.67%) were male, and the male-to-female ratio was 2.41:1. A total of 55 cases (73.33%) had respiratory tract infection with fever. Seventy cases had lesions in the basal ganglia (46 left, 24 right). All patients were treated conservatively without thrombolytic therapy. Intravenous immunoglobulin treatment was given to children with fever and drowsiness.Conclusion: Infection was an important risk factor for children with AIS in China. Infection and thrombophilia risk factors were more likely to occur in isolation. The stroke lesions commonly occurred in the basal ganglia region.

Abstract TMP51: Pre-existing Atherosclerotic Risk Factors Increase Short-Term Ischemic Stroke Risk After Traumatic Head or Neck Injury

Introduction: Trauma is an established risk factor for ischemic stroke in the young. We speculated that atherosclerotic disease, increasingly prevalent at younger ages, could predispose to dissection or artery-to-artery embolism after trauma. In a cohort of young patients with head or neck trauma, we aimed to measure the association of atherosclerotic risk factors with short-term ischemic stroke risk. Methods: Nested case-control study of patients (birth to 50 years old) with head or neck trauma while enrolled in a population-based Northern California integrated healthcare delivery system, 1997-2011. Within the trauma cohort, we identified ischemic stroke ICD-9 codes within 4 weeks of head or neck injury. A panel of neurologists reviewed charts to confirm cases of arterial ischemic stroke and determine whether stroke was attributed to trauma. Three controls per case were randomly identified from the trauma cohort. Atherosclerotic risk factors were abstracted from charts only when documented prior to trauma. We compared cases to controls using logistic regression. Results: The trauma cohort included 120,494 emergency encounters or hospital admissions for head or neck injury over the 15-year study period. We confirmed 45 cases of arterial ischemic stroke attributed to trauma and randomly identified 135 stroke-free controls for comparison. Stroke risk was not associated with sex or race/ethnicity, but was age-related: for each decade older, stroke risk increased 70% (OR 1.7, 95% CI 1.4-2.2). Other pre-existing atherosclerotic risk factors also increased stroke risk. Cases were more likely than controls to have atherosclerotic risk factors documented in the medical record prior to trauma, including hypertension, diabetes mellitus, elevated cholesterol, and history of smoking (Table). Conclusions: Pre-existing atherosclerotic risk factors appear to increase short-term ischemic stroke risk after head or neck injury.

Abstract 52: Inflammatory Biomarkers Correlate With Etiology in Childhood Arterial Ischemic Stroke

Introduction: Etiologies of childhood arterial ischemic stroke (AIS) are heterogeneous, yet most cases fall into one of three subtypes: arteriopathic, cardioembolic, or idiopathic. Circulating inflammatory mediators could play a role in the pathogenesis of each subtype, whether through inflammatory injury to arterial or cardiac endothelium, or by promoting thrombosis. Hypothesis: Patterns of post-stroke serum inflammation in children will differ by etiologic subtype. Methods: From the “Vascular effects of Infection in Pediatric Stoke” (VIPS) study cohort (355 cases of AIS, ages 29 days through 18 years), we selected cases centrally classified as arteriopathic (N=119), spontaneous cardioembolic (N=58; excluding peri-procedural cardioembolic AIS), or idiopathic (N=82). We used Luminex assays to measure serum concentrations (pg/mL) of 20 inflammatory biomarkers selected for their correlation with adult AIS or arteriopathy in other settings. We compared analyte concentrations across the three etiologic subtypes in unadjusted and adjusted analyses. Results: Serum samples were collected at a median of 5.5 days post-stroke (IQR 3, 10 days). Compared to children with idiopathic AIS, those with cardioembolic AIS had higher levels of four analytes (IL-6, IL-8, IL-10, IP-10), even after adjustment for age, sex, infarct volume, and other potential confounders (Table). Children with arteriopathic AIS, on the other hand, had higher levels of two analytes (IL-10, IP-10), and lower levels of another two (fractalkine, MCP-1). Conclusion: Patterns of post-AIS serum inflammation differ by stroke subtype in children, and may provide clues to stroke pathogenesis. We will perform network analyses using unsupervised machine learning approaches to elucidate these patterns further.

C.01.03 Treatment objectives and outcomes through the course of schizophrenia

Mechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children.We report 3 new cases of pediatric stroke treated using mechanical thrombectomy. Two cases of AIS and 1 case of CVT were identified from 2018 pediatric stroke clinic records.Thrombectomy was successful in 1 of the 2 AIS cases and in the CVT case. None of the children were asymptomatic after thrombectomy. One AIS case had good recovery than developed dystonia which responded to treatment; the second AIS case had residual hemiplegia; and the child with CVT had mild school problems.Mechanical thrombectomy is being increasingly used for pediatric stroke treatment. This study and recent literature reviews suggest thrombectomy holds promise as a treatment for selected pediatric stroke patients. Questions remain about the safety and efficacy of thrombectomy in children with stroke since large randomized controlled studies are not yet feasible.

Mortality After Pediatric Arterial Ischemic Stroke.

Cerebrovascular disease is among the top 10 causes of death in US children, but risk factors for mortality are poorly understood. Within an international registry, we identify predictors of in-hospital mortality after pediatric arterial ischemic stroke (AIS). Neonates (0-28 days) and children (29 days-<19 years) with AIS were enrolled from January 2003 to July 2014 in a multinational stroke registry. Death during hospitalization and cause of death were ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality. Fourteen of 915 neonates (1.5%) and 70 of 2273 children (3.1%) died during hospitalization. Of 48 cases with reported causes of death, 31 (64.6%) were stroke-related, with remaining deaths attributed to medical disease. In multivariable analysis, congenital heart disease (odds ratio [OR]: 3.88; 95% confidence interval [CI]: 1.23-12.29; P = .021), posterior plus anterior circulation stroke (OR: 5.36; 95% CI: 1.70-16.85; P = .004), and stroke presentation without seizures (OR: 3.95; 95% CI: 1.26-12.37; P = .019) were associated with in-hospital mortality for neonates. Hispanic ethnicity (OR: 3.12; 95% CI: 1.56-6.24; P = .001), congenital heart disease (OR: 3.14; 95% CI: 1.75-5.61; P < .001), and posterior plus anterior circulation stroke (OR: 2.71; 95% CI: 1.40-5.25; P = .003) were associated with in-hospital mortality for children. In-hospital mortality occurred in 2.6% of pediatric AIS cases. Most deaths were attributable to stroke. Risk factors for in-hospital mortality included congenital heart disease and posterior plus anterior circulation stroke. Presentation without seizures and Hispanic ethnicity were also associated with mortality for neonates and children, respectively. Awareness and study of risk factors for mortality represent opportunities to increase survival.

Differentiating arterial ischaemic stroke from migraine in the paediatric emergency department

To estimate the strengths of association between clinical features and migraine or arterial ischaemic stroke (AIS) in children presenting to the emergency department. Eighty-four children with migraine, prospectively recruited from 2009 to 2010, were compared with 55 children with AIS, prospectively/retrospectively recruited from 2003 to 2010. Odds ratios were calculated via logistic regression to measure associations between clinical features and process-of-care factors, and migraine and AIS. Median age was 13years 5months (interquartile range 12y 11mo-13y 10mo) for migraine and 5years (interquartile range 3y 7mo-8y) for patients with AIS. All cases of AIS and 30% of migraine cases underwent neuroimaging. Over 40% of children with migraine had vomiting, numbness, or visual disturbance; other symptoms were uncommon. Fifty-five per cent had no signs on physician assessment. Weakness or speech disturbance were common in patients with AIS. Significant clinical features associated with increased odds of AIS included sudden symptom onset, weakness, seizures, speech disturbance, and ataxia, and signs of face, arm, or leg weakness, inability to walk, dysarthria, dysphasia, and altered consciousness (p<0.05). Significant features associated with decreased odds of AIS included older age, vomiting, visual, sensory, other symptoms, and absent focal signs on assessment (p<0.05). Presenting features can discriminate childhood AIS from migraine. These differences inform decisions about urgency and type of neuroimaging in children presenting to the emergency department with brain attack symptoms. Weakness, seizures, ataxia, speech, or walking difficulties are more frequent in arterial ischaemic stroke (AIS). Vomiting, visual, or sensory disturbance and absent focal signs are more frequent in migraine. Identifying features of AIS and migraine guides neuroimaging in children with brain attack symptoms.

Quantitative Arterial Tortuosity Suggests Arteriopathy in Children With Cryptogenic Stroke.

Quantitative arterial tortuosity (QAT) is a ratio of vessel length between 2 points to the shortest linear distance between same points. QAT has been reported as an imaging biomarker of arteriopathy in pediatric arterial ischemic stroke (AIS) because of dissection and transient cerebral arteriopathy. We sought to determine whether QAT abnormalities are present in other subtypes of pediatric AIS. Children with AIS-absent conventional biomarkers of arteriopathy and case-controls who underwent magnetic resonance angiography were classified by stroke mechanism. The primary study population consisted of cryptogenic AIS cases. AIS with bow hunter physiology and cardiogenic emboli were also evaluated. AIS because of nontraumatic dissection served as positive controls. Patients without vascular risk factors served as negative controls. Segmental QAT of cervicocerebral arteries were measured using automated image processing and differences between groups analyzed. In negative controls, QAT showed significant age-related variability for most arterial segments. Positive controls showed significantly increased QAT of the distal extracranial vertebral arteries (VAs) and decreased QAT of the intracranial VA relative to negative controls. Cryptogenic stroke and bow hunter physiology cases were similar to positive controls showing increased QAT of the distal extracranial VA and decreased QAT of the intracranial VA relative to negative controls. Cardioembolic stroke cases were similar to negative controls showing decreased QAT of the distal extracranial VA and increased QAT of the intracranial VA relative to positive controls. Pediatric cryptogenic stroke is frequently associated with cervicocerebral arteriopathies expressing altered QAT. QAT may be a diagnostic biomarker of arteriopathy in pediatric AIS.

Abstract 15: Mortality After Pediatric Arterial Ischemic Stroke: Results From the International Paediatric Stroke Study

Introduction: Stroke is reported among the top 10 causes of death in children in the US. In the Kids’ Inpatient Database, older age and Hispanic ethnicity were risk factors for mortality after pediatric ICH. Limited data is available regarding risk factors for death after pediatric arterial ischemic stroke (AIS). Objective: To identify predictors of in-hospital mortality in pediatric patients hospitalized with AIS. Methods: Neonates (0-28 days) and children (29 days- &lt;19 years) with AIS were enrolled from 1/2003 to 7/2014 in the IPSS multinational stroke registry. Death prior to hospital discharge and cause of death was ascertained from medical records. Logistic regression was used to analyze associations between risk factors and in-hospital mortality. Results: Fourteen of 915 neonates (1.5%) and 74/2,285 children (3.2%) died during hospitalization. Of 54 cases with reported causes of death, 32 (59%) were related to AIS (herniation 2, brain death 10, ICH/hemorrhagic transformation 5, care withdrawal due to stroke severity 15), with the remaining deaths attributed to underlying medical disease. Of 356 children with Pediatric NIH Stroke Scale (PedNIHSS) scores, median PedNIHSS was 19 (IQR 14-27) among the 13 children who died and 7 (IQR 3-12) among the 343 children who did not die. In multivariable analysis, congenital heart disease (OR 4.1, 95%CI 1.3-13, p=0.018) and posterior plus anterior circulation stroke (OR 4.3, 95%CI 1.3-14, p=0.017) were associated with in-hospital mortality for neonates, while higher PedNIHSS [OR 1.11 (per 1 point PedNIHSS increase), 95%CI 1.03-1.19, p=0.004], Hispanic ethnicity (OR 7.6, 95%CI 1.8-32.3, p=0.006), and cardiac disease (OR 7.5, 95%CI 1.5-38.6, p=0.015) were associated with in-hospital mortality for children. Conclusions: In-hospital mortality occurred in about 2% of pediatric AIS cases with nearly 60% attributable to stroke. Risk factors for in-hospital mortality included cardiac disease and stroke severity, factors also associated with mortality in adults. Hispanic ethnicity, a factor associated with mortality in childhood ICH, was also associated with mortality after childhood AIS; the underlying reasons are unclear. Additional information is needed on stroke-related deaths after hospitalization.

Population-based study of ischemic stroke risk after trauma in children and young adults.

To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.

Parvovirus B19 Infection in Children With Arterial Ischemic Stroke.

Case-control studies suggest that acute infection transiently increases the risk of childhood arterial ischemic stroke. We hypothesized that an unbiased pathogen discovery approach utilizing MassTag-polymerase chain reaction would identify pathogens in the blood of childhood arterial ischemic stroke cases. The multicenter international VIPS study (Vascular Effects of Infection in Pediatric Stroke) enrolled arterial ischemic stroke cases, and stroke-free controls, aged 29 days through 18 years. Parental interview included questions on recent infections. In this pilot study, we used MassTag-polymerase chain reaction to test the plasma of the first 161 cases and 34 controls enrolled for a panel of 28 common bacterial and viral pathogens. Pathogen DNA was detected in no controls and 14 cases (8.7%): parvovirus B19 (n=10), herpesvirus 6 (n=2), adenovirus (n=1), and rhinovirus 6C (n=1). Parvovirus B19 infection was confirmed by serologies in all 10; infection was subclinical in 8. Four cases with parvovirus B19 had underlying congenital heart disease, whereas another 5 had a distinct arteriopathy involving a long-segment stenosis of the distal internal carotid and proximal middle cerebral arteries. Using MassTag-polymerase chain reaction, we detected parvovirus B19-a virus known to infect erythrocytes and endothelial cells-in some cases of childhood arterial ischemic stroke. This approach can generate new, testable hypotheses about childhood stroke pathogenesis.

Utility of Neurovascular Imaging in Acute Neonatal Arterial Ischemic Stroke

To evaluate the prevalence of magnetic resonance angiography (MRA) findings and clinically characterize neonates with arterial ischemic stroke (AIS) who have abnormal or variable vasculature. This was a single-center, retrospective study of patients with neonatal stroke from 1991 to 2012. We reviewed charts and neuroimaging, including MRA, in neonates with AIS. Clinical data of patients with MRA findings were compared with the control group of neonates with AIS and a normal MRA. We identified 142 cases of neonatal AIS, of which 81 patients had magnetic resonance imaging and MRA. Among the neonates with arterial neuroimaging, 29 had arterial findings (for a prevalence rate of 20%-35%). The majority of the findings were stenotic or hypoplastic branches. Two patients had presumed carotid artery dissection. Low Apgar scores and the presence of sepsis were significantly (P <.05) more common in neonates with MRA findings. The prevalence of arterial abnormalities or variations in neonatal AIS has been underestimated because neurovascular imaging is often not performed. We recommend an MRA for neonates with AIS, particularly those who have low Apgar scores and/or sepsis, to rule out a vasculopathy that may warrant therapeutic intervention.

The Prevalence of Celiac Disease in Children With Arterial Ischemic Stroke.

The association between arterial ischemic stroke (AIS) and celiac disease (CD) has been described in only a few cases in adults and children. We aim to determine the prevalence of CD in children and adolescents with AIS. We investigated serum levels of tissue transglutaminase antibody immunoglobulin (Ig)A and total IgA from 76 children with AIS and in a healthy control group of 102 children. Study participants who were positive for tissue transglutaminase IgA antibodies underwent a duodenal biopsy. A total of 2 patients in the AIS group (2.26%) and 2 in the control group (1.96%) had positive serum tissue transglutaminase antibody (P=0.89; 95% confidence interval, -5.05 to 6.89). Duodenal biopsy confirmed CD in only 1 patient who had AIS. In the present study, children with acute arterial stroke did not exhibit a higher prevalence rate of CD compared with healthy controls. Therefore, the screening test for CD is not a necessary part of the management of AIS in children. However, cases of recurrent AIS could be examined for CD.

Abnormal neurodevelopmental outcomes are very likely in cases of bilateral neonatal arterial ischaemic stroke.

Neonatal arterial ischaemic stroke (AIS) is an important cause of severe neurological disability. This study aimed to analyse the clinical manifestations and outcomes of AIS patients. We enrolled neonates with AIS admitted to Severance Children's Hospital and Gangnam Severance Hospital between 2008 and 2015. AIS was confirmed using magnetic resonance imaging (MRI). We retrospectively reviewed the clinical manifestations, MRI findings, electroencephalography (EEG) findings and neurodevelopmental outcomes. The study comprised 29 neonates (18 boys). The mean follow-up period was 15.4 months (range 6-44 months), and the mean age at diagnosis was 8.1 days. Seizure was the most common symptom (66%). Bilateral involvement was more common than unilateral involvement (52%). The middle cerebral artery was the most commonly identified territory (79%). Abnormal EEG findings were noted in 93% of the cases. Neurodevelopment was normal in 11 (38%) patients, while cerebral palsy and delayed development were noted in eight (28%) and six (21%) patients, respectively. Patients with bilateral involvement were very likely to have abnormal neurodevelopmental outcomes. Our study showed that abnormal neurodevelopmental outcomes were very likely after cases of neonatal AIS with bilateral involvement, and clinicians should consider early and more effective interventions in such cases.