scholarly journals Socioeconomic determinants of outcome after childhood arterial ischemic stroke

Neurology ◽  
2018 ◽  
Vol 91 (6) ◽  
pp. e509-e516 ◽  
Author(s):  
Lori C. Jordan ◽  
Nancy K. Hills ◽  
Christine K. Fox ◽  
Rebecca N. Ichord ◽  
Paola Pergami ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Low Income ◽  
Maternal Education ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Rehabilitation Services ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Annual Household Income ◽  
Neurologic Outcomes

ObjectiveTo determine whether lower socioeconomic status (SES) is associated with worse 1-year neurologic outcomes and reduced access to rehabilitation services in children with arterial ischemic stroke (AIS).MethodsFrom 2010 to 2014, the Vascular effects of Infection in Pediatric Stroke (VIPS) observational study prospectively enrolled and confirmed 355 children (age 29 days–18 years) with AIS at 37 international centers. SES markers measured via parental interview included annual household income (US dollars) at the time of enrollment, maternal education level, and rural/suburban/urban residence. Receipt of rehabilitation services was measured by parental report. Pediatric Stroke Outcome Measure scores were categorized as 0 to 1, 1.5 to 3, 3.5 to 6, and 6.5 to 10. Univariate and multivariable ordinal logistic regression models examined potential predictors of outcome.ResultsAt 12 ± 3 months after stroke, 320 children had documented outcome measurements, including 15 who had died. In univariate analysis, very low income (<US $10,000), but not other markers of SES, was associated with worse outcomes (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.43–6.88, p = 0.004). In multivariable analysis, including adjustment for stroke etiology, this association persisted (OR 3.17, 95% CI 1.18–8.47, p = 0.02). Income did not correlate with receiving rehabilitation services at 1 year after stroke; however, quality and quantity of services were not assessed.ConclusionsIn a large, multinational, prospective cohort of children with AIS, low income was associated with worse neurologic outcomes compared to higher income levels. This difference was not explained by stroke type, neurologic comorbidities, or reported use of rehabilitation services. The root causes of this disparity are not clear and warrant further investigation.

Abstract WMP111: Socioeconomic Determinants of Outcome After Childhood Arterial Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lori C Jordan ◽  
Nancy K Hills ◽  
Warren Lo ◽  
Rebecca N Ichord ◽  
Christine K Fox ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Maternal Education ◽  
Recurrent Stroke ◽  
Pediatric Population ◽  
Neurological Deficits ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Vascular Effects ◽  
Middle Income ◽  
Poor Outcome

Introduction: Lower socioeconomic status (SES) is associated with poorer outcome after adult stroke. In a large cohort of children with arterial ischemic stroke (AIS), we determined 12-month neurological outcome and tested the hypothesis that SES is a determinant of outcome in children. Methods: From 2009-2014, the Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS (29 days-18 years) at 37 international centers, including 3 in lower and middle income (LAMI) countries. Outcome was assessed at 12 months via the recurrence and recovery questionnaire (RRQ) parental report of the pediatric stroke outcome measure (PSOM). Poor outcome was defined as a PSOM of ≥1. Results: Of 355 children, outcome was available for 310 (87%) at a median of 12 months (IQR 11-13). Ten children died prior to hospital discharge and 4 by 12 months. Outcomes improved from discharge to 12 months (Figure). Of 23 cases in LAMI countries, 88% had an income <USD$10,000, compared to 11% of 287 cases in non-LAMI countries. Overall, only 39% LAMI cases had a good outcome, versus 61% of non-LAMI cases (p=0.052). There were too few cases to analyze outcome predictors in LAMI countries. However, in non-LAMI countries, income did not independently predict poor outcome (OR 1.7, 95% CI 0.57, 4.8, for income <$10,000 vs. >$100,000). Other markers of SES (maternal education level and rural/suburban/urban residence) also did not predict outcome. Independent predictors of poor outcome included moderate (OR 4.6, 95% CI 2.0, 11) or severe (OR 21, 95% CI 7.1, 60) neurological deficits at discharge (compared to no deficits) and recurrent stroke (OR 3.5, 95% CI 1.5, 8.3). Conclusion: Outcomes after childhood stroke may be worse in LAMI countries, although we were underpowered to study this subgroup. Within non-LAMI countries, SES does not appear to impact outcome in children, unlike reports in adults, perhaps reflecting better access to rehabilitation services in the pediatric population.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals

2021 ◽  
pp. 1-8
Author(s):  
Maria Gladkikh ◽  
Hugh J. McMillan ◽  
Andrea Andrade ◽  
Cyrus Boelman ◽  
Ishvinder Bhathal ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Tertiary Care ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Pediatric Hospitals ◽  
First Choice ◽  
Similarities And Differences ◽  
Pre Treatment ◽  
Magnetic Resonance Imaging Mri ◽  
Iv Tpa

ABSTRACT: Background: Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management. Methods: We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains. Results: Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75–0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2). Conclusions: Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.

Abstract WP7: Leukoaraiosis And Outcomes After Intra-arterial Therapy In Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Dan-Victor V Giurgiutiu ◽  
Albert J Yoo ◽  
Kaitlin Fitzpatrick ◽  
Zeshan Chaudhry ◽  
Lee H Schwamm ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Artery Occlusion ◽  
Post Stroke ◽  
Good Functional Outcome ◽  
Grade 3 ◽  
Risk Of Hemorrhage

Background: Selecting patients most likely to benefit (MLTB) from intra-arterial therapy (IAT) is essential to assure favorable outcomes after intervention for acute ischemic stroke (AIS). Leukoaraiosis (LA) has been linked to infarct growth, risk of hemorrhage after IV rt-PA, and poor post-stroke outcomes. We investigated whether LA severity is associated with AIS outcomes after IAT. Methods: We analyzed consecutive AIS subjects from our institutional GWTG-Stroke database enrolled between 01/01/2007-06/30/2009, who met our pre-specified criteria for MLTB: CTA and MRI within 6 hours from last known well, NIHSS score ≥8, baseline DWI volume (DWIv) ≤ 100 cc, and proximal artery occlusion and were treated with IAT. LA volume (LAv) was assessed on FLAIR using validated, semi-automated protocols. We analyzed CTA to assess collateral grade; post-IAT angiogram for recanalization status (TICI score ≥2B); and the 24-hour CT for symptomatic ICH (sICH). Logistic regression was used to determine independent predictors of good functional outcome (mRS≤ 2) and mortality at 90 days post-stroke. Results: There were 48 AIS subjects in this analysis (mean age 69.2, SD±13.8; 55% male; median LAv 4cc, IQR 2.2-8.8cc; median NIHSS 15, IQR 13-19; median DWIv 15.4cc, IQR 9.2-20.3cc). Of these, 34 (72%) received IV rt-PA; 3 (6%) had sICH; 21 (44.7%) recanalized; and 23 (50%) had collateral grade ≥3. At 90 days, 15/48 (36.6%) were deceased and 15/48 had mRS≤ 2. In univariate analysis, recanalization (OR 6.2, 95%CI 1.5-25.5), NIHSS (OR 0.8 per point, 95%CI 0.64-0.95), age (OR 0.95 per yr, 95%CI 0.89-0.99) were associated with good outcome, whereas age (OR 1.1, 95%CI 1.01-1.14) and HTN (OR 5.6, 95%CI 1.04-29.8) were associated with mortality. In multivariable analysis including age, NIHSS, recanalization, collateral grade, and LAv, only recanalization independently predicted good functional outcome (OR 21.3, 95%CI 2.3-199.9) and reduced mortality (OR 0.15, 95%CI 0.02-1.12) after IAT. Conclusions: LA severity is not associated with poor outcome in patients selected MLTB for IAT. Among AIS patients considered likely to benefit from IAT, only recanalization independently predicted good functional outcome and decreased mortality.

Abstract 160: Paradoxical Effect of Smoking on Mortality in the patients Admitted with Acute Ischemic Stroke

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Lee H Schwamm
Keyword(s):  
Ischemic Stroke ◽  
Myocardial Ischemia ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Oral Intake ◽  
Lower Mortality ◽  
Paradoxical Effect ◽  
Multicenter Studies ◽  
Stroke Registry

Introduction: Compared to those who never smoked, a paradoxical effect of smoking on reducing mortality in patients admitted with myocardial ischemia has been reported. We sought to determine if this effect was present in patients hospitalized with ischemic stroke. Methods: Using the local Get with the Guidelines-Stroke registry, we analyzed 4,305 consecutively admitted ischemic stroke patients (Mar 2002-Dec 2011). The sample was divided into smokers vs. ex or non-smokers. The main outcome of interest was the overall inpatient mortality. Multivariable analysis included factors significant at p<0.05 in univariate analysis. Results: Compared to non-smokers, tobacco smokers were younger, more frequently male and presented with fewer stroke risk factors such as hypertension, hyperlipidemia, diabetes, coronary artery disease and atrial fibrillation. Smokers also had a lower median NIHSS and fewer received tPA. Patients in both groups had similar adherence to early antithrombotics, dysphagia screening prior to oral intake and DVT prophylaxis (Table 1). Smoking was associated with lower all cause in-hospital mortality (6.6% vs. 12.4%; unadjusted OR 0.46; CI [0.34 - 0.63]; p < 0.05). In multivariable analysis, adjusted for age, gender, ethnicity, HTN, DM, HL, CAD, A.fib, NIHSS and tPA at an outside hospital, smoking remained independently associated with lower mortality (adjusted OR 0.66; CI [0.44-0.98]; p < 0.05). (Table 2) Conclusion: Similar to myocardial ischemia, smoking was independently associated with lower mortality in acute ischemic stroke. This effect may be due to tobacco induced changes in cerebrovascular resting tone or vasoreactivity, or may be due in part to residual confounding (e.g., differences in predicted outcome from stroke subtypes, or wishes regarding life sustaining therapies). Larger, multicenter studies are needed to confirm the finding and determine the role of in hospital complications and the effect on 30 day and 1 year mortality.

Abstract WMP113: Headache At Stroke Onset Is Present In Half Of All Older Children With Arterial Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lori L Billinghurst ◽  
Adam Kirton ◽  
Steven Pavlakis ◽  
Jo Ellen Lee ◽  
Luigi Titomanlio ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Right Hemisphere ◽  
Female Gender ◽  
Stroke Onset ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Anterior Circulation ◽  
Stroke Registry ◽  
Young Infants ◽  
Individual Site

Introduction: Headache at stroke onset occurs in up to a quarter of adults and is associated with younger age, female gender, right hemisphere and cerebellar infarcts. Little is known about headache at stroke onset in children. Methods: Children (29 days-18 years) with clinical and radiographic confirmation of arterial ischemic stroke were prospectively enrolled in the International Pediatric Stroke Study from 2003-2014. Details regarding demographics, stroke presentation and infarct location were obtained from the multi-center, pediatric stroke registry. Headache at stroke presentation was classified and annotated in the registry by the individual site investigators as present, absent or unclear. Results: We analyzed 2103 children. Half of all subjects ≥ 6 yo reported headache at stroke onset (N=509/1047, 49%; Figure). Headache was less prevalent in children < 6 yo (N=112/1056, 11%; p<0.001), though headache presentation was more commonly classified as unclear (10% vs 32%; p<0.001). In children ≥ 6 yo, headache was significantly associated with papilledema (p = 0.03) and vertigo (p = 0.01), but not with hemiparesis (p = 0.11), visual field deficit (p = 0.90), aphasia (p = 0.35), dysarthria (p = 0.44), or ataxia (p = 0.50). Headache was more common in posterior than anterior circulation infarcts (p<0.001). There was a significant association between headache and right or bilateral hemisphere infarcts (p = 0.04) but not with gender (p = 0.76). Conclusion: Headache is more prevalent in children than adults at stroke ictus and shares similar associations, including infarcts involving the posterior circulation and right hemisphere. Headache may be under-reported in young infants and children due to pre-verbal stages of development. These findings have implications for early identification and treatment of pediatric stroke and warrant further investigation in prospective studies to distinguish stroke from more common benign mimics, including migraine.

scholarly journals Diffusion imaging of cerebral diaschisis in neonatal arterial ischemic stroke

2015 ◽  
Vol 42 (S1) ◽  
pp. S15-S15
Author(s):  
R Srivastava ◽  
T Rajapakse ◽  
J Roe ◽  
X Wei ◽  
A Kirton
Keyword(s):  
Ischemic Stroke ◽  
Diffusion Imaging ◽  
Population Based ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Long Term Outcomes ◽  
Primary Injury

Background: Neonatal arterial ischemic stroke (NAIS) is a leading cause of brain injury and cerebral palsy. Diffusion-weighted imaging (DWI) has revolutionized NAIS diagnosis and outcome prognostication. Diaschisis refers to changes in brain areas functionally connected but structurally remote from primary injury. We hypothesized that acute DWI can demonstrate cerebral diaschisis and evaluated associations with outcome. Methods: Subjects were identified from a prospective, population-based research cohort (Calgary Pediatric Stroke Program). Inclusion criteria were unilateral middle cerebral artery NAIS, DWI MRI within 10 days of birth, and >12-month follow-up (Pediatric Stroke Outcome Measure, PSOM). Diaschisis was quantified using a validated software method. Diaschisis-scores were corrected for infarct size and compared to outcomes (Mann-Whitney). Results: From 20 eligible NAIS, 2 were excluded for image quality. Of 18 remaining, 16 (89%) demonstrated diaschisis. Thalamus (88%) was most often involved. Age at imaging was not associated with diaschisis. Long-term outcomes available on 13 (81%) demonstrated no association between diaschisis score and PSOM categories. Conclusion: Cerebral diaschisis occurs in NAIS and can be quantified with DWI. Occurrence is common and should not be mistaken for additional infarction. Determining additional clinical significance will depend on larger samples with long-term outcomes.

Acute Treatments and Early Outcomes of Childhood Arterial Ischemic Stroke: First Analysis of the International Pediatric Stroke Study.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1978-1978 ◽  
Author(s):  
Neil A Goldenberg ◽  
Timothy J. Bernard ◽  
Anne Gordon ◽  
Heather J. Fullerton ◽  
Gabrielle A. deVeber
Keyword(s):  
Ischemic Stroke ◽  
South America ◽  
Antithrombotic Therapy ◽  
Geographic Region ◽  
Treatment Selection ◽  
Pediatric Stroke ◽  
Arterial Ischemic Stroke ◽  
Antithrombotic Treatment ◽  
Stroke Study ◽  
International Pediatric

Abstract Background: In pediatric arterial ischemic stroke (AIS) clinical treatment trials are lacking and treatment practices variable. Factors determining treatment selection and outcomes are important to delineate. Objective: We aimed to (1) describe acute treatments and outcomes in childhood AIS, and (2) test putative variables for treatment selection, and outcome in a prospective-retrospective multicenter international study. Methods: We evaluated treatments and early outcomes of children enrolled in the International Pediatric Stroke Study with AIS diagnosed at &gt;28 days and &lt;18 years of age from 2003 to 2007. Putative predictor variables for antithrombotic treatment selection included age, clinical AIS subtypes, geographic region (Asia, Australia, Canada, Europe, South America, and U.S.), and diagnosis pre- versus post-2004 (when pediatric AIS guidelines published). Results: Among 676 children with acute AIS, anticonvulsants and antibiotics were administered acutely in 57% and 40%, respectively; use of each decreased with age (P&lt;0.001). Acute anticoagulants (AAC; with/without concomitant anti-platelet therapy) were selected more frequently than either acute anti-platelet agents (AAP) alone or no acute antithrombotic treatment (NAAT) (43% AAC vs. 28% AAP alone and 29% NAAT). NAAT decreased with increasing age. AAC was most frequent in cerebral/cervical arterial dissection (n=52; 75% AAC vs. 6% AAP) and least frequent with moyamoya syndrome (n=72; 31% AC vs. 43% AAP). AAC was most common in Europe and Canada, AAC vs. AAP relatively balanced in the U.S., and AAP most common in Asia and South America. AAC use was similar pre- versus post-2004. At hospital discharge 71% had neurological deficits independent of age, subtype, or geographical region. Mortality at discharge was 3%. Conclusions: Acute anticoagulation is frequently but not uniformly employed in childhood AIS. With current treatment, the prevalence of neurological deficit at hospital discharge is high. These findings reflect disparity in published guidelines and highlight the need for clinical trials to reduce adverse outcomes. Figure 1. Acute antithrombotic therapy in childhood AIS, by geographic region. Figure 1. Acute antithrombotic therapy in childhood AIS, by geographic region.

scholarly journals Focal Cerebral Arteriopathy of Childhood: Clinical and Imaging Correlates

Stroke ◽  
2021 ◽  
Author(s):  
Gabriela Oesch ◽  
Francisco A. Perez ◽  
Mark S. Wainwright ◽  
Dennis W.W. Shaw ◽  
Catherine Amlie-Lefond
Keyword(s):  
Ischemic Stroke ◽  
Pacific Northwest ◽  
Outcome Measure ◽  
Stroke Recurrence ◽  
Pediatric Stroke ◽  
Stroke Outcome ◽  
Arterial Ischemic Stroke ◽  
Electronic Health Record Data ◽  
Anterior Circulation ◽  
Cerebral Arteriopathy

Background and Purpose: Focal cerebral arteriopathy (FCA) of childhood with unilateral stenosis of the anterior circulation is reported to account for up to one-quarter of childhood arterial ischemic stroke, with stroke recurrence in 25% of cases. Limited knowledge regarding pathophysiology and outcome results in inconsistent treatment of FCA. Methods: Children with arterial ischemic stroke due to FCA between January 1, 2009, and January 1, 2019, were retrospectively identified at our institution which serves the US Pacific Northwest region. Electronic health record data, including neuroimaging studies, were reviewed, and the Pediatric Stroke Outcome Measure at 1 year was determined as the primary clinical end point. Results: Fifteen children were diagnosed with FCA, accounting for 19% of children with cerebral arteriopathies (n=77). Among children with FCA, the median age at the time of stroke was 6.8 years (Q1–Q3, 1.9–14.0 years). Four (20%) patients had worsening stroke, 3 of whom had concurrent infection. Three (20%) FCA cases were treated with steroids, one of whom had worsening stroke. Median Pediatric Stroke Outcome Measure at 1 year was 1.0 (Q1–Q3, 0.6–2.0). Variability in arteriopathy severity was observed within many patients. Patients with more severe arteriopathy using the Focal Cerebral Arteriopathy Severity Score had larger strokes and were more likely to have worsening stroke. The most common long-term neurological deficit was hemiparesis, which was present in 11 (73%) patients and associated with middle cerebral artery arteriopathy and infarcts. Conclusions: FCA may be less common than previously reported. Neuroimaging in FCA can help identify patients at greater risk for worsening stroke.

Factors Affect on development and clinical course of ischemic stroke in children

2016 ◽  
Vol 7 (4) ◽  
pp. 102-108 ◽  
Author(s):  
Alexey V Minin ◽  
Alexander B Palchik ◽  
Svetlana D Plotnikova
Keyword(s):  
Ischemic Stroke ◽  
Internal Capsule ◽  
Least Square Method ◽  
Structural Features ◽  
Partial Least Square ◽  
Least Square ◽  
Arterial Ischemic Stroke ◽  
Neurologic Outcomes ◽  
Neuroimaging Data ◽  
Occipital Lobes

Child strokes cause persistent neurologic impairment affecting on quality of life. Prophylaxis cerebral infarction in children promoted by Identification of factors influencing on development of ischemic stroke. 47 children with arterial ischemic stroke confirmed by MRI or CT was enrolled in cohort study. All children has focal neurological symptomatic which was assessed by pedNIHSS, PSOM, British muscular strength scale. General cerebral symptoms precede focal neurologic impairments in 67% cases. Fact of head trauma was documented in 55% observed children. Seizures occurs in 24% cases in acute period ischemic stroke. As major part of children had lacunar infarction in middle cerebral artery origin, so motor dysfunctions was admitted in clinical curse of general cases. By neuroimaging data we defined lacunar infarctions mainly in basal ganglia, thalamus and internal capsule. In the rest 5 cases - in cortex, white matter, frontal, parietal and occipital lobes, cerebellum and brain stem. In 10 children during observation over time the secondary haemorrhage at ischaemic site was detected. Besides post-ischemic alterations additional structural features was assessed in neuroimaging study. Calcification in white mater of brain was reviled in one third children with ischemic stroke (33,4%). Overwhelming majority calcifications in white mater of brain was diagnosed in lenticular-striatal arteries infarctions. Latent factors structure influenced on severity neurologic outcomes was received by partial least square method (PLS). Acquired data emphasize importance of mind depression, vertigo, dysphagia as poor outcome predictors.

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