Cause Of Stroke In Children Research Articles

Remote ischemic conditioning prevents ischemic cerebrovascular events in children with moyamoya disease: a randomized controlled trial.

Moyamoya disease (MMD) is a significant cause of childhood stroke and transient ischemic attacks (TIAs). This study aimed to assess the safety and efficacy of remote ischemic conditioning (RIC) in children with MMD. In a single-center pilot study, 46 MMD patients aged 4 to 14years, with no history of reconstructive surgery, were randomly assigned to receive either RIC or sham RIC treatment twice daily for a year. The primary outcome measured was the cumulative incidence of major adverse cerebrovascular events (MACEs). Secondary outcomes included ischemic stroke, recurrent TIA, hemorrhagic stroke, revascularization rates, and clinical improvement assessed using the patient global impression of change (PGIC) scale during follow-up. RIC-related adverse events were also recorded, and cerebral hemodynamics were evaluated using transcranial Doppler. All 46 patients completed the final follow-up (23 each in the RIC and sham RIC groups). No severe adverse events associated with RIC were observed. Kaplan-Meier analysis indicated a significant reduction in MACEs frequency after RIC treatment [log-rank test (Mantel-Cox), P = 0.021]. At 3-year follow-up, two (4.35%) patients had an ischemic stroke, four (8.70%) experienced TIAs, and two (4.35%) underwent revascularization as the qualifying MACEs. The clinical improvement rate in the RIC group was higher than the sham RIC group on the PGIC scale (65.2% vs. 26.1%, P < 0.01). No statistical difference in cerebral hemodynamics post-treatment was observed. RIC is a safe and effective adjunct therapy for asymptomatic children with MMD. This was largely due to the reduced incidence of ischemic cerebrovascular events.

Genetic Variants Associated with the Risk of Stroke in Sickle Cell Anemia: Systematic Review and Meta-Analysis

Sickle cell anemia (SCA) is the most common cause of stroke in children. As it is a rare disease, studies investigating the association with complications like stroke in SCD have small sample sizes. Here, we performed a systematic review and meta-analysis of the studies exploring an association of genetic variants with stroke to get a better indication of their association with stroke. PubMed and Google Scholar were searched to identify studies that had performed an association analysis of genetic variants for the risk of stroke in SCA patients. After screening of eligible studies, summary statistics of association analysis with stroke and other general information were extracted. Meta-analysis was performed using the fixed effect method on the tool METAL and forest plots were plotted using the R program. The random effect model was performed as a sensitivity analysis for loci where significant heterogeneity was observed. 407 studies were identified using the search term and after screening 37 studies that cumulatively analyzed 11,373 SCA patients were included. These 37 studies included a total of 2,222 SCA patients with stroke, predominantly included individuals of African ancestry (N = 16). Three of these studies performed whole exome sequencing while 35 performed single nucleotide-based genotyping. Though the studies reported association with 132 loci, meta-analyses could be performed only for 12 loci that had data from two or more studies. After meta-analysis we observed that four loci were significantly associated with risk for stroke: -α3.7 kb Alpha-thalassemia deletion (P = 0.00000027), rs489347-TEK (P = 0.00081), rs2238432-ADCY9 (P = 0.00085), rs11853426-ANXA2 (P = 0.0034), and rs1800629-TNF (P = 0.0003396). Ethnic representation of regions with a high prevalence of SCD like the Mediterranean basin and India needs to be improved for genetic studies on associated complications like stroke. Larger genome-wide collaborative studies on SCD and associated complications including stroke need to be performed.

Cerebral sinovenous thrombosis as a cause of subdural hemorrhage in the pediatric population: Is there a correlation?

Cerebral sinovenous thrombosis is an increasingly recognized cause of stroke in children and neonates. Its true incidence appears to be underestimated. Despite being a rare event, certain studies have found a correlation between subdural hemorrhage and cerebral sinus thrombosis. The literature suggests that spontaneous cerebral sinovenous thrombosis in the pediatric population may lead to the occurrence of a subdural hemorrhage. In this report, we present a case of cerebral venous thrombosis associated with chronic subdural hematoma and review the literature to highlight the importance of these conditions. An 11-year-old boy was admitted in the neurosurgery department with headache and a neurological examination without changes. The imaging studies identified a heterogeneous subdural collection in the fronto-temporo-parietal region. The patient underwent surgical drainage of the subdural hematoma, and the procedure was performed without complications. The magnetic resonance and angiography showed an extensive thrombosis of the superior sagittal sinus, extending downward to the occipital sinus and partially to the right transverse sinus. Appropriate management in the diagnosis and an early treatment of dural sinus thrombosis associated with subdural hemorrhage can reduce the risk of recurrence and improve the clinical outcome.

Plasma exosomal microRNAs are non-invasive biomarkers of moyamoya disease: A pilot study

BackgroundAs a progressive cerebrovascular disease, Moyamoya Disease (MMD) is a common cause of stroke in children and adults. However, the early biomarkers and pathogenesis of MMD remain poorly understood. Methods and materialThis study was conducted using plasma exosome samples from MMD patients. Next-generation high-throughput sequencing, real-time quantitative PCR, gene ontology analysis, and Kyoto Encyclopaedia of Genes and Genomes pathway analysis of ideal exosomal miRNAs that could be used as potential biomarkers of MMD were performed. The area under the Receiver Operating Characteristic (ROC) curve was used to evaluate the sensitivity and specificity of biomarkers for predicting events. ResultsExosomes were successfully isolated and miRNA-sequence analysis yielded 1,002 differentially expressed miRNAs. Functional analysis revealed that they were mainly enriched in axon guidance, regulation of the actin cytoskeleton and the MAPK signaling pathway. Furthermore, 10 miRNAs (miR-1306-5p, miR-196b-5p, miR-19a-3p, miR-22-3p, miR-320b, miR-34a-5p, miR-485-3p, miR-489-3p, miR-501-3p, and miR-487-3p) were found to be associated with the most sensitive and specific pathways for MMD prediction. ConclusionsSeveral plasma secretory miRNAs closely related to the development of MMD have been identified, which can be used as biomarkers of MMD and contribute to differentiating MMD from non-MMD patients before digital subtraction angiography.

Why Would a Child Have a Stroke?

Identifying the etiology of childhood arterial ischemic stroke helps prevent stroke recurrence. In addition, stroke may herald a serious underlying condition requiring treatment, such as acquired heart disease, malignancy, or autoimmune disorder. Evidence-based guidelines exist for adults to identify and treat common risk factors for primary and secondary stroke, including hypertension, diabetes, elevated lipids, atrial fibrillation, and sleep apnea, which are rarely relevant in children. However, guidelines do not exist in pediatrics. Identifying the cause of childhood stroke may be straightforward or may require extensive clinical and neuroimaging expertise, serial evaluations, and reassessment based on the evolving clinical picture. Risk factors may be present but not necessarily causative, or not causative until a triggering event such as infection or anemia occurs. Herein, we describe strategies to determine stroke etiology, including challenges and potential pitfalls.

Moyamoya Disease

Abstract Moyamoya disease is a rare disease that causes progressive narrowing of the intracranial internal carotid arteries, resulting in reduced blood supply to the brain, leading to strokes. It is a major cause of childhood stroke. A 10-year-old boy presented with recurrent left-hemispheric transient ischemic attack and seizures. On evaluation, the child was diagnosed as having bilateral moyamoya disease. The child was prescribed antiplatelets and antiepileptics and advised to drink 2 liters of water a day and to avoid dehydration. He was admitted for an elective revascularization surgery. Left-side superficial temporal artery to middle cerebral artery bypass with encephaloduroarteriomyosynangiosis was done. The child was monitored in the postoperative neurosurgery intensive care unit for 1 day for any postprocedure complications. Postoperative course was uneventful, and the child was discharged on the sixth postoperative day with instruction to continue antiplatelets and antiseizure medications. The outcome of cerebral revascularization in moyamoya disease is good, with reduction in ischemic events and seizures. Postoperative nursing care in neurosurgery units is important in preventing complications and achieving better outcomes.

Case Report Presentation: Measles as the Cause of Cerebral Venous Sinus Thrombosis in Childhood

The major cause of stroke in children is cerebral venous sinus thrombosis (CVST), which may cause neurological impairment and even death. The most frequent causes of CVST in kids are infections, followed by anemia, and then dehydration. Despite the existence of a safe and reliable vaccination, measles is an infectious viral infection that continues to be a major cause of death in young children worldwide. With a high morbidity and death rate, measles may result in neurologic consequences, such as acute demyelinating encephalomyelitis (ADEM), coma, seizures, or obtundation. In this case, a 4-year-old Syrian girl with status epilepticus and an altered sensorium was brought to the emergency room and was later identified as having CVST. There have never been any reports of CVST with measles.

Moyamoya Angiopathy with Growth Hormone Deficiency in 13 Years and 10 Years Old Boys Brothers in Iraq

Moyamoya disease is a rare, progressive cerebrovascular disease marked by stenosis and occlusion of the distal internal carotid arteries and branches of the circle of Willis, leading to creation of a collateral network of blood vessels at the base of the brain. It has been found to be a significant cause of childhood stroke. We would like to present two cases of moyamoya angiopathy with a growth hormone deficiency, in 13-year-old and 10-year-old brothers in Iraq. Hypothalamic-pituitary dysfunction may complicate Moyamoya angiopathy, which is attributed to chronic cerebrovascular insufficiency. Therefore, it is worth checking and regularly monitoring for this problem, especially in growing children and adolescents, to achieve normal growth and development.

Transcranial doppler as screening method for sickling crises in children with sickle cell anemia: a latin America cohort study

BackgroundSickle cell anemia (SCA) is the leading cause of childhood stroke. We aimed to evaluate whether altered cerebral flow velocities, as measured by transcranial Doppler (TCD), are associated with vaso-occlusive complications in addition to stroke in pediatric SCA patients.MethodsWe evaluated 37 children aged between 2 and 16 years with SCA who underwent screening for TCD between January 2012 and October 2018. Genotypic profiles and demographic data were collected, TCD examinations were performed during follow-up, and the presence of sickling crises was compared. Survival analyses were performed using simple frailty models, in which each predictor variable was analyzed separately in relation to the occurrence of a sickling crisis.ResultsThe variables related to sickle cell crises in the univariate analysis were peak systolic velocity (PSV) in the middle cerebral artery (MCA), hazard ratio (HR) 1.01 (1.00—1.02) p = 0.04; end-diastolic velocity (EDV) in the MCA, HR 1.02 (1.01—1.04) p = 0.01; time average mean maximum velocity (TAMMV) in the basilar artery (BA), HR 1.02 (1.00—1.04) p = 0.04; hemoglobin, HR 0.49 (0.38—0.65) p < 0.001; hematocrit, HR 0.78 (0.71—0.85) p < 0.001; leukocyte counts, HR 1.1 (1.05—1.15) p < 0.001; platelets counts, HR 0.997 (0.994—0.999) p = 0.02; and reticulocyte numbers, HR 1.14 (1.06—1.23) p < 0.001.ConclusionsOur results indicate PSV and EDV in the MCA and TAMMV in the BA as markers of risk for the occurrence of sickling crises in SCA.

Multidisciplinary Stroke Pathway for Children Supported With Ventricular Assist Devices.

Mechanical circulatory support (MCS), including ventricular assist device (VAD) support, is a leading cause of stroke in children; however, existing pediatric stroke recommendations do not apply to many pediatric VAD patients. We sought to develop a multidisciplinary pathway to improve timely and effective acute stroke care and examine the early performance of the pathway in expediting stroke care. Stakeholders from pediatric heart failure, cardiac intensive care, neurology, interventional radiology, neuroradiology, neurosurgery, pharmacy, and adult VAD care convened at Stanford University in August 2017 to discuss the challenges of providing high-quality acute stroke care to children on VAD support, and to develop multidisciplinary acute stroke pathways. Stakeholders identified multiple barriers to providing timely acute stroke care to pediatric VAD patients. These include delayed recognition of stroke, and lack of clarity related to the optimal imaging technique, when to emergently reverse antithrombotic therapy (AT), pediatric indications for thrombectomy and cranial decompression, and strategies to avoid unnecessary serial CTS. Four stroke pathways were created including evaluation and management of the pediatric patient with (1) an acute neurologic change before an imaging diagnosis; (2) an arterial ischemic stroke (AIS); (3) an intracerebral hemorrhage (ICH); and (4) a subdural hematoma (SDH). With the implementation of the stroke pathway, the median time-to-first-CT image decreased by 43 minutes from 66 to 23 minutes ( P < 0.001) while the proportion with a CT within 30 minutes increased from 0% to 67% ( P < 0.001). Despite a variety of challenges, multidisciplinary consensus can be achieved on a rapid stroke management pathway for children on VAD support that addresses important barriers to timely stroke care. Although too few stoke events occurred to differentiate clinical outcomes, the time-to-first-CT image was significantly shorter after pathway implementation.

Epidemiology of Stroke in Sickle Cell Disease.

Sickle cell disease is the most common cause of stroke in childhood, both ischaemic and haemorrhagic, and it also affects adults with the condition. Without any screening or preventative treatment, the incidence appears to fall within the range 0.5 to 0.9 per 100 patient years of observation. Newborn screening with Penicillin prophylaxis and vaccination leading to reduced bacterial infection may have reduced the incidence, alongside increasing hydroxyurea prescription. Transcranial Doppler screening and prophylactic chronic transfusion for at least an initial year has reduced the incidence of stroke by up to 10-fold in children with time averaged mean of the maximum velocity >200 cm/s. Hydroxyurea also appears to reduce the incidence of first stroke to a similar extent in the same group but the optimal dose remains controversial. The prevention of haemorrhagic stroke at all ages and ischaemic stroke in adults has not yet received the same degree of attention. Although there are fewer studies, silent cerebral infarction on magnetic resonance imaging (MRI), and other neurological conditions, including headache, epilepsy and cognitive dysfunction, are also more prevalent in sickle cell disease compared with age matched controls. Clinical, neuropsychological and quantitative MRI screening may prove useful for understanding epidemiology and aetiology.

Venous sinus thrombosis in pediatrics. Case series of a tertiary hospital.

Venous sinus thrombosis (VST) is a rare entity in pediatrics, probably under-diagnosed and poten tially serious, described as a cause of stroke in childhood. To describe the clinical presenta tion, risk factors, treatment, and evolution of pediatric patients with VST. Re trospective study of patients admitted to a referral hospital, diagnosed with VST, aged between one month and seventeen years, from January 2011 to December 2019. The following data were re viewed: age at diagnosis, sex, signs and symptoms of presentation, predisposing mechanisms, study of thrombophilias, treatment and duration of treatment, follow-up protocol, long-term sequelae, and mortality. Due to their differences in clinical presentation, the sample was divided into two age groups: young children between 1 month and 5 years and older children and adolescents between 6 and 17 years. 17 patients were diagnosed with VST, 45% were women, with a median age of 4.5 years. The most frequent symptoms in older children (6-17 years old) were headache (80%) and diplopia (60%). In children under 5 years old, the most frequent clinical presentation was cerebellar ataxia (42%), asymptomatic (34%), and headache (25%). In 23.5% of the total, VST was a casual fin ding in neuroimaging. 13 patients presented relevant histories such as complicated otitis media with mastoiditis (53%), severe traumatic head injury (6%), and resection of a space-occupying lesion of the brain (6%). 23% of the cases were idiopathic and in 23% there were prothrombotic factors. The treatment of choice in all patients was low-molecular-weight heparin. During the short-term follow- up, 11.8% presented self-limited neurological symptoms. One patient presented long-term paresis of the sixth paired cranial nerve. There were no deaths or recurrences of the episode in our series. VST is a rare entity and it usually appears with signs and symptoms of intracranial hy pertension. It is a potentially serious condition and early diagnosis and treatment can help minimize long-term sequelae.

DIAPH1 Variants in Non–East Asian Patients With Sporadic Moyamoya Disease

Moyamoya disease (MMD), a progressive vasculopathy leading to narrowing and ultimate occlusion of the intracranial internal carotid arteries, is a cause of childhood stroke. The cause of MMD is poorly understood, but genetic factors play a role. Several familial forms of MMD have been identified, but the cause of most cases remains elusive, especially among non-East Asian individuals. To assess whether ultrarare de novo and rare, damaging transmitted variants with large effect sizes are associated with MMD risk. A genetic association study was conducted using whole-exome sequencing case-parent MMD trios in a small discovery cohort collected over 3.5 years (2016-2019); data were analyzed in 2020. Medical records from US hospitals spanning a range of 1 month to 1.5 years were reviewed for phenotyping. Exomes from a larger validation cohort were analyzed to identify additional rare, large-effect variants in the top candidate gene. Participants included patients with MMD and, when available, their parents. All participants who met criteria and were presented with the option to join the study agreed to do so; none were excluded. Twenty-four probands (22 trios and 2 singletons) composed the discovery cohort, and 84 probands (29 trios and 55 singletons) composed the validation cohort. Gene variants were identified and filtered using stringent criteria. Enrichment and case-control tests assessed gene-level variant burden. In silico modeling estimated the probability of variant association with protein structure. Integrative genomics assessed expression patterns of MMD risk genes derived from single-cell RNA sequencing data of human and mouse brain tissue. Of the 24 patients in the discovery cohort, 14 (58.3%) were men and 18 (75.0%) were of European ancestry. Three of 24 discovery cohort probands contained 2 do novo (1-tailed Poisson P = 1.1 × 10-6) and 1 rare, transmitted damaging variant (12.5% of cases) in DIAPH1 (mammalian diaphanous-1), a key regulator of actin remodeling in vascular cells and platelets. Four additional ultrarare damaging heterozygous DIAPH1 variants (3 unphased) were identified in 3 other patients in an 84-proband validation cohort (73.8% female, 77.4% European). All 6 patients were non-East Asian. Compound heterozygous variants were identified in ena/vasodilator-stimulated phosphoproteinlike protein EVL, a mammalian diaphanous-1 interactor that regulates actin polymerization. DIAPH1 and EVL mutant probands had severe, bilateral MMD associated with transfusion-dependent thrombocytopenia. DIAPH1 and other MMD risk genes are enriched in mural cells of midgestational human brain. The DIAPH1 coexpression network converges in vascular cell actin cytoskeleton regulatory pathways. These findings provide the largest collection to date of non-East Asian individuals with sporadic MMD harboring pathogenic variants in the same gene. The results suggest that DIAPH1 is a novel MMD risk gene and impaired vascular cell actin remodeling in MMD pathogenesis, with diagnostic and therapeutic ramifications.

Risk Factors and Outcome of Overt Stroke in Sickle Cell Patients Admitted in Two Reference Hospitals in Yaounde and Douala

Background: Worldwide, the prevalence of sickle cell disease (SCD) as of 2016 was estimated at 2%; that is 300,000 births annually. This study was focused on homozygous sickle cell disease which leads to several complications notably hemolytic crises, aplastic crises and vaso-occlusive crises like stroke. Sickle cell disease is the most common cause of childhood stroke. Stroke occurs in 17% - 24% of sickle cell children worldwide. Objectives: To determine the risk factors for overt stroke and outcome at discharge in sickle cell disease patients admitted in two reference hospitals in Cameroon. Method: This was a case-control study in two reference hospitals in Yaounde and Douala, carried out over the duration of 4 months, covering a 5-year period (December 2013 to December 2018). Included in the study, were all homozygous sickle cell children aged 6 months to 16 years during that period with or without stroke. A total of 1734 patients fulfilled the inclusion criteria. Out of these, 49 stroke patients participated and 687 were selected as controls. Data was collected from the patients’ files and books on a pretested data collection form, then entered in the software C.S Pro 7.1 before analysis. Stroke outcome at discharge was assessed using the modified Rankin scale (mRs) with structured interview. A patient was classified as good outcome if mRs 3 and poor outcome if mRs ≥ 3. Statistical analysis was done with SPSS software version 22.0 for Windows. Results: A total of 736 patients participated in the study. Out of these, 391 (53.1%) were males and 345 (46.9%) were females. Overt stroke was found to have an estimated hospital prevalence of 3.29% in this population. Several risk and associated factors were identified such as frequent rate of acute chest syndrome (p = 0.001), low steady state haemoglobin (p 0.001) and previous stroke (p = 0.002). A poor outcome was observed in 16 (32.7%) of them. Conclusion: The occurrence of stroke in this population is 3.29% and several factors were associated with its occurrence.

A Panel of Exosome-Derived miRNAs of Cerebrospinal Fluid for the Diagnosis of Moyamoya Disease.

BackgroundMoyamoya disease (MMD) is an important cause of stroke in children and young adults in Asia. To date, diagnosis remains challenging due to varying clinical manifestations and unknown pathogenesis. The study aims to identify cerebrospinal fluid (CSF) exosomal microRNAs (exomiRs) that can serve as a novel diagnostic biomarker for diagnosis and assess its clinical applications.MethodsCSF samples were taken from 31 MMD patients and 31 healthy controls. Initial screening of miRNA expression was performed on samples pooled from MMD patients and controls using microarray and validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). The diagnostic accuracy of the potential exosomal miRNAs was evaluated using receiver operating characteristic curve analyses in an independent patient cohort. The potential pathways regulated by the miRNAs was also determined using bioinformatics analysis.ResultsThe microarray results demonstrated that six exomiRs were dysregulated in the MMD patients compared to the controls. Using qRT-PCR, we validated four of the miRNAs (miR-3679-5p, miR-6165, miR-6760-5p, and miR-574-5p) as a biomarker for MMD diagnosis. The four exomiRs showed enhanced sensitivity (75%) and specificity (93.75%) in terms of differentiating MMD patients from healthy subjects [area under the curve (AUC) = 0.9453]. Pathway enrichment analysis for potential targets of six exomiRs identified proteins involved in cell adhesion and junction formation in the brain.ConclusionsWe identified a novel and highly sensitive exomiRs signature for MMD detection and explored its potential targets using bioinformatics analysis.

A-061 Early Childhood Prefrontal Cortex Stroke and Changes in Connections to Other Regions

Abstract Objective Sickle-cell anemia is a leading congenital cause of stroke in childhood. Such strokes can lead to cognitive deficits, stroke in the prefrontal cortex leading to inattention, impulsivity, and poor executive control. This case study examines a 23-year-old African American male who suffered from a stroke in his prefrontal cortex at age 3. Neuroimaging confirmed stroke location, but the patient had an atypical pattern of reported cognitive deficits. Method The patient was assessed in an out-patient practice. The individual was assessed with a clinical interview and comprehensive Neuropsychological Battery. The battery included cognitive and psychological measures with free-standing and imbedded validity measures. Results Cognitive testing demonstrated significant impairment in visuospatial processing speed, visual abilities, and decision making and executive control. This pattern of impairment suggests that the patient is still suffering from his stroke, which likely damaged the connective tissue of the occipital and parietal lobes, and the prefrontal cortex. The patient was diagnosed with Mild Neurocognitive Disorder in perceptual-motor and executive functioning. Conclusions These results suggest that despite the neuroplastic abilities of the brain at early ages, the neurodevelopment of individuals who suffer from stroke in early childhood is likely to be altered and contributes to cognitive impairments in early adulthood. Long-term cognitive sequelae in the form of deficits in visual perceptual skills, suggest that frontal connections to other regions in the brain may be impacted. Therefore, this case highlights that even a localized stroke in a child can lead to broader deficits if that area of the brain interacts with other areas.

Trivial trauma as a cause of stroke in children

Ischaemic stroke resulting from minor head injury are rare in children, as trauma usually results in intracranial bleed. We report a case who presented with right sided hemiplegic stroke due to trivial trauma. 11 year old girl who was previously healthy, presented with right sided facial palsy and ipsilateral hemiplegia of one day. MRI brain showed left sided middle cerebral artery territory infarct. MR angiography showed left middle cerebral artery territory infarct involving the left gangliocapsular region, left corona radiata and left frontotemporal lobe, suggestive of occlusion. On enquiry mother revealed fall from stairs 3 days back.

Abstract TMP111: Risk Factors Associated With Watershed Stroke in Pediatric Patients Undergoing Fontan Operation

Introduction: Cardiac disease is one of the leading causes of stroke in children. In an effort to separate pulmonary and systemic circulations, patients with single ventricle physiology undergo the Fontan surgery. Watershed strokes have been reported as a complication of Fontan surgery but literature on its prevalence and associated risk factors is lacking. Methods: Retrospective review of records of patients who underwent Fontan operation at our center from 2007 to 2018. Demographic, clinical, imaging, and outcome data were documented for all patients. Key risk factors evaluated:cardiac diagnosis, presence of significant AV-valve regurgitation, poor ventricular function, cardio-pulmonary bypass (CPB) time, Hematocrits, mean arterial pressure (Map) and significance of post-operative resuscitation measured by cardiac index and vasoactive infusion score. Univariate logistic regression was used for analyses, and a p-value of &lt;0.05 was considered statistically significant. Results: We identified 149 patients;14 (10%) had clinical evidence and radiographic confirmation of a watershed stroke. There were no arterial ischemic strokes.From all the variables analyzed (Table 1), patients with significant A-V valve regurgitation pre- and post-operatively, depressed single ventricular function, and underlying diagnosis of hypoplastic left heart syndrome (HLHS) were at a higher risk for watershed strokes. No other risk factors were identified. (Table 1). All had no significant motor deficits at discharge. Conclusion: At our center, watershed infarcts occurred in 10% of patients undergoing Fontan surgery. Cardiac disease diagnosis and factors associated to cardiac function were significant risk factors for watershed stroke rather than surgical related variables.

Cerebral Venous Sinus Thrombosis in Children: A Study from a Tertiary Care Hospital of Eastern India.

ABSTRACTContext:Cerebral venous sinus (sinovenous) thrombosis (CVST) in childhood is a rare, but under recognized, disorder, typically of multifactorial etiology, with neurologic sequelae apparent in up to 40% of survivors and mortality approaching 10%.Aim:The aim of this study was to enlist the patients diagnosed as CVST younger than 14 years of age and to diagnose the etiology along with radiological correlation.Settings and Design:This prospective clinical study was conducted for 2 years in the Department of Neurology, Srirama Chandra Bhanja Medical College & Hospital (SCBMCH), Cuttack, Odisha, India.Materials and Methods:All the patients were enlisted in a prestructured format with detailed clinico-radiological evaluation. Treatment was performed according to recent guidelines. Outcome after 3 months was analyzed. Ethical clearance was obtained from institutional ethics committee.Statistical Analysis:Data were statistically analyzed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA).Results:The total number of patients included in the study was 30. Of them, six were neonates. The most common provocative factor was tuberculous meningitis. Phototherapy after neonatal hyperbilirubinemia was prominent cause in neonatal age group. Multiple sinus involvement was seen in most of the patients. Transverse sinus was the most common sinus to be involved.Conclusion:CVST is an underdiagnosed but important cause of stroke in childhood, occurring most often in the neonatal period. Mortality and morbidity are significant. Infections hyper coagulative disorders are the two primary associations. Magnetic resonance venography is the investigation of choice. Early diagnosis with management along with plan for secondary prevention can save from catastrophic consequences.

P.036 Stroke in people with Down Syndrome: a retrospective study

Background: There are only few studies approaching the prevalence and cause of stroke in children and adults with Down Syndrome (DS). Methods: We did a retrospective study of our cohort of 4962 patients of Jerome Lejeune Institute since 2007. We collected age of stroke, clinical presentation, cause (TOAST classification), treatment and clinical course. Results: We identified 20 patients from 6 to 56 years old .In all cases, it was a stroke of ischemic origin.: 8 children with a prevalence of 0.33%. 4 had a cardio-embolic origin, 3 secondary to Moya-Moya syndrome and one of undetermined origin. 12 adults (21 to 52 years old) with a prevalence of 0.46%.The majority of the causes of these ischemic strokes are indeterminate (9 of 12), Conclusions: We found a low prevalence and an ischemic cause in all cases of stroke, which differs from the general population. For pediatric stroke, the causes are expected thromboembolic in a context of heart disease most often or secondary to a Moya-Moya syndrome. For adult strokes, the average age is younger than that in the general population and the cause is indeterminate in most cases. We must better explore our patients to identify the risk factors in DS population.