Acute Ischemic Stroke in a Young Child and Its Association with SARS-CoV-2 Infection

The coronavirus disease 2019 (COVID-19) in children has been shown to have lower morbidity and mortality in children as compared with adults. The neurological complications related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly reported in children, yet the cerebrovascular complications are rare. We report a case of a toddler who presented with right-sided hemiparesis and motor aphasia, with an antecedent history suggestive of COVID-19 infection. The child tested negative on the nasopharyngeal swab for real-time reverse transcription-polymerase chain reaction (RT-PCR), but the serology for anti-SARS-CoV-2 IgG assay was positive. The neuroimaging showed an acute infarct in the left middle cerebral artery territory. A detailed evaluation for causes of childhood stroke was unrevealing, except for the presence of severe iron deficiency anemia (IDA). The child was diagnosed as acute ischemic stroke (AIS) most probably secondary to mild COVID-19 infection. The objective of this case report is to explain the possibility of AIS after a mild COVID-19 infection, complicated by the underlying severe IDA. Therefore, an association between COVID-19 and stroke in children needs to be emphasized and RT-PCR for SARS-CoV-2 as well as serological assay must be included in the workup of stroke in the young.

213 Can Styloid Process and Internal Carotid Artery Anatomy Be Used to Predict Carotid Artery Dissection?

Aim Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Method Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Results Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5mm and styloid process-internal carotid distance was 5.14mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection. Conclusions In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements cannot be used to predict the possibility of a CCAD following trauma.

O28 Can styloid process and internal carotid artery anatomy be used to predict carotid artery dissection?

Introduction Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Method Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Result Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection. Conclusion In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma. Take-home Message Anatomy of the styloid process and calcification of the styloid-hyoid ligament are highly variable and many independent factors may contribute to the risk of cervical carotid artery dissection. Radiological measurements of the styloid process alone cannot be used to predict risk and likelihood of cervical carotid artery dissection.

Magnetic resonance imaging derived cardiac first pass perfusion in cryptogenic ischemic stroke in the young

Funding Acknowledgements Type of funding sources: None. Introduction Up to 50% of ischemic strokes in adults aged between 18 and 50 are cryptogenic by nature. Heart has been a hypothesised source. Purpose: Purpose of the study was to investigate the wash in and wash out of gadolinium based contrast agent in the left atrial appendage, and cardiac chambers in first pass cardiac magnetic resonance imaging. Methods The study comprised 30 patients with first-ever cryptogenic ischemic stroke and 30 age and gender matched stroke-free controls included in the prospective multicenter study Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers and Outcome (SECRETO; NCT01934725). Cardiac magnetic resonance imaging was performed on all participants with a 1.5T magnetic resonance system. Dynamic contrast enhanced T1 weighted first pass perfusion images were acquired in the superior vena cava, the left atrial appendage (Fig. 1), and the left ventricle. The images were analyzed for time-intensity curves (Fig. 2), and results were normalised to individual heart rate. Arrival times, peak times, areas under the curves, relative blood flows (defined as area under the curve/full width at half maximum), and maximum and minimum rates of bolus wash in / wash out were calculated. Results The wash in of the contrast agent bolus was similar in patients and controls. Arrival times and peak timings showed similar characteristics in patients and controls in the left atrial appendage (arrival time: 12.4 [2.3] vs. 13.5 [3.6] cardiac cycles, p = 0.657; peak time: 19.6 [5.1] vs. 19.8 [6.9] cardiac cycles, p = 0.929) and the left atrium (arrival time: 12.2 [2.8] vs. 13.0 [3.6] cardiac cycles, p = 0.535; peak time: 18.7 [5.5] vs. 18.1 [5.2] cardiac cycles, p = 0.790). Areas under under the curves and relative blood flows were similar in patients and controls. A significant difference between patients and controls was found in the wash out rate of gadolinium in the left ventricle (-28 [11] vs. -36 [13] 1/cardiac cycles, p = 0.012), indicating slightly slower wash out in the patients. Conclusions Cryptogenic ischemic stroke in the young is not associated with prolonged blood flow in the left atrial appendage or left atrium. There were no significant differences in the first pass perfusion between subjects and healthy controls. However, there might be a slight tendency for stagnation of blood flow in the left ventricles of cryptogenic stroke patients.

Stroke in the Young - online medical school held on the Instagram social network: results and prospects

Funding Acknowledgements Type of funding sources: None. Purpose. To study the potential of Instagram as a hosting platform for an online school in order to improve the programmes of primary prevention of stroke in young people. Material and methods. At the first stage of the study, October 2020, the ‘Stroke in the Young’ online school was announced on 8 medical blogs. For the online school a special account was created under insult.u.molodjh (1,354 followers). As part of the online school are 8 posts and 6 open online lectures. At the second stage, to study the effectiveness of the online school, 50 respondents (4% male, mean age 24.4 ± 5.2 years) were selected from 1,354 students by an electronic random number generator and asked to fill in the questionnaire on ‘Awareness of Risk Factors (RF) and Symptoms of Stroke Among Social Network Users’ before and after the school completion. Results. The total number of people who listened to and read the material of the online school is 8,712 people; the overall engagement is 470 people. 48% of the respondents of the 2nd stage were 18 to 44 years old; 76% of the respondents had post-secondary education. Of the respondents, 16% were employed in the healthcare system and 22% had a history of stroke, 76% had independently searched for information on stroke earlier and 60% received this information passively from healthcare professionals in 2020. The most significant parameters affecting awareness of stroke RF were employment in the healthcare system (alcohol consumption, OR 0.186, CI 0.043–0.804, p = 0.02; high blood pressure (BP), OR 14.945, CI 0.959–233.012, p = 0.05); getting informed about stroke in 2020 (cardiovascular diseases (CVD), OR 3.561, CI 1.093–11.605, p = 0.03; obesity, OR 3.044, CI 1.011–9.163, p = 0.04) and post-secondary education (high BP, OR 6.001, CI 0.920–39.136, p = 0.06; CVD, OR 0.268, CI 1.093–11.605, p = 0.03). Factors that affected the awareness of individual stroke symptoms were getting informed about stroke in 2020 (p = 0.02), education (p = 0.005), history of strokes (p = 0.01) and employment in the healthcare system (p = 0.05). When the questionnaire was completed again after training, it was shown that the online training leads to better chances of improving health literacy with respect to a number of RF (cholesterol awareness (OR 4.6, CI 1.1–18.7), smoking as a risk factor for stroke (OR 3.3, CI 1.3–8.1)) and stroke symptoms (face drooping, OR 5.1, CI 1.0–27.4; very severe headache, OR 3.1, CI 1.0–9.4). Conclusions. Instagram can be used to host online schools in order to improve programmes for primary prevention of stroke in young people. The online school has aroused interest among both healthcare professionals and people without medical education, including those with a history of stroke. Online training led to better chances of improving health literacy with respect to a number of RF, such as awareness of high cholesterol and smoking, and contributed to improving health literacy for such stroke symptoms as face drooping and very severe headache.

Thrombophilia Testing After Ischemic Stroke

Thrombophilia testing is frequently performed after an ischemic stroke, particularly when cryptogenic. However, there is minimal evidence supporting a significant association between most conditions assessed through thrombophilia testing and ischemic stroke, and the rationale for thrombophilia testing in many clinical situations remains uncertain. In this topical review, we review and contextualize the existing data on the risks, predictors, and outcomes of thrombophilic conditions in patients with ischemic stroke. We report that inherited thrombophilias have an uncertain relationship with ischemic stroke. Conversely, antiphospholipid syndrome, an acquired immune-mediated thrombophilia, seems to be a strong risk factor for arterial thromboembolic events, including ischemic stroke, and especially among young patients. Our findings suggest that certain circumstances may warrant targeted thrombophilia testing, such as stroke in the young, cryptogenic stroke, and high estrogen states. Future prospective studies should investigate the utility and cost effectiveness of thrombophilia testing in various stroke settings, including among patients with patent foramen ovale; as well as the optimal secondary stroke prevention regimen in patients with confirmed thrombophilia, particularly if no other potential stroke mechanism is identified.