Acute arterial ischemic stroke in children: single-center experience

Abstract

Background

Arterial ischemic stroke (AIS) is an increasingly common disorder in childhood that causes severe mortality and morbidity.

Objective

To emphasize the importance of early diagnosis and treatment of AIS cases, as well as the early initiation of physical therapy.

Methods

We retrospectively reviewed the medical records of 23 patients aged 1 month to 18 years, who were admitted with acute neurological complaints and diagnosed radiologically with AIS at the Bursa Yüksek İhtisas Training and Research Hospital, a tertiary healthcare facility, between January 2016 and June 2020.

Results

Neurological deficit was the most common (12 patients; 52%) complaint, followed by seizure in 5 patients (21%), facial paralysis in 5 patients (21%), and visual impairment in 3 patients (13%). We performed brain computed tomography (CT) scans in 12 (52%) patients at the first application, and infarction was detected in 8 (66%). Infarction was in the cerebrum in 19 (82%) patients. Mutations of the methylenetetrahydrofolate reductase (MTHFR; A1298C and 677C > T) gene were found most frequently. Cardiac anomalies were detected in 7 (30%) patients, and 2 patients had ventriculoperitoneal shunts.

Conclusion

Arterial ischemic stroke presents very different clinical findings, such as hiccups, anisocoria, and upward gaze paralysis. We wanted to emphasize the importance of cranial CT scanning because sometimes MRI is not always easily performed in children. Concomitant conditions, such as intracranial operation, ventriculoperitoneal shunt, and hypochondroplasia, may increase the risk of stroke.

Keywords

Cerebral Infarction - Magnetic Resonance Imaging - BE-FAST - Child

Authors' Contributions

Conceptualization: MB; Data curation: MB, AE, CH; Formal analysis: MB, AE; Investigation: CH; Methodology: AE, CH; Resources: MB; Writing – original draft: MB; Writing – review & editing: AE.

Data Availability Statement

The contents underlying the research text are included in the manuscript.

Conflict of Interest

The authors have no conflict of interest to declare.

Editor-in-Chief: Ayrton Roberto Massaro https://orcid.org/0000-0002-0487-5299.

Associate Editor: Jamary Oliveira Filho https://orcid.org/0000-0003-1915-0423.

Publikationsverlauf

Eingereicht: 04. Mai 2024

Angenommen: 06. April 2025

Artikel online veröffentlicht:
25. Juni 2025

• References

• 1 Agrawal N, Johnston SC, Wu YW, Sidney S, Fullerton HJ. Imaging data reveal a higher pediatric stroke incidence than prior US estimates. Stroke 2009; 40 (11) 3415-3421
• 2 Fox CK, Johnston SC, Sidney S, Fullerton HJ. High critical care usage due to pediatric stroke: results of a population-based study. Neurology 2012; 79 (05) 420-427
• 3 Hajek CA, Yeates KO, Anderson V, Mackay M, Greenham M, Gomes A, Lo W. Cognitive outcomes following arterial ischemic stroke in infants and children. J Child Neurol 2014; 29 (07) 887-894
• 4 deVeber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol 2000; 15 (05) 316-324
• 5 Bonfert MV, Badura K, Gerstl J, Borggraefe I, Heinen F, Schroeder S. et al Childhood stroke: Awareness, interest, and knowledge amoung the pediatric community. Front Pediatr 2018; 6: 182
• 6 Mackay MT, Wiznitzer M, Benedict SL, Lee KJ, Deveber GA, Ganesan V. International Pediatric Stroke Study Group. Arterial ischemic stroke risk factors: the International Pediatric Stroke Study. Ann Neurol 2011; 69 (01) 130-140
• 7 Amlie-Lefond C, Wainwright MS. Organizing for acute arterial ischemic stroke in children. Stroke 2019; 50 (12) 3662-3668
• 8 Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D. et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
• 9 Alshekhlee A, Geller T, Mehta S, Storkan M, Al Khalili Y, Cruz-Flores S. Thrombolysis for children with acute ischemic stroke: a perspective from the kids' inpatient database. Pediatr Neurol 2013; 49 (05) 313-318
• 10 Adams HP, Bendixen BH, Kapelle LJ, Biller J, Love BB, Gordon DL, Marsh III EE. Classification of subtype of acute ischaemic stroke. Definitions for use in a multicenter clinical trial TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
• 11 Hajat C, Coshall C, Rudd AG, Patel M, Bhalla A, Howard R, Wolfe CD. The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register. J Neurol Sci 2001; 190 (1-2): 79-85
• 12 De Veber G. Cerebrovascular Disease. In: Swaiman KF, Ashwal S, Ferriero DM. editors Pediatric Neurology: Principles and Practice. 4th ed.. St. Louis: Mosby; 2006. . p. 1759-1801
• 13 Mallick AA, Ganesan V, Kirkham FJ, Fallon P, Hedderly T, McShane T. et al Diagnostic delays in paediatric stroke. J Neurol Neurosurg Psychiatry 2015; 86 (08) 917-921
• 14 Gerstl L, Weinberger R, Heinen F, Bonfert MV, Borggraefe I, Schroeder AS. et al Arterial ischemic stroke in infants, children, and adolescents: results of a Germany-wide surveillance study 2015-2017. J Neurol 2019; 266 (12) 2929-2941
• 15 Yock-Corrales A, Varela-Bulgarelli F, Barboza C, Gutierrez-Mata A, Mackay MT, Babl F. Presentation of acute childhood stroke in a tertiary pediatric emergency department. Pediatr Emerg Care 2018; 34 (08) 552-557
• 16 Lanska MJ, Lanska DJ, Horwitz SJ, Aram DM. Presentation, clinical course, and outcome of childhood stroke. Pediatr Neurol 1991; 7 (05) 333-341
• 17 Golomb MR, Dick PT, MacGregor DL, Curtis R, Sofronas M, deVeber GA. Neonatal arterial ischemic stroke and cerebral sinovenous thrombosis are more commonly diagnosed in boys. J Child Neurol 2004; 19 (07) 493-497
• 18 Lee J, Croen LA, Backstrand KH, Yoshida CK, Henning LH, Lindan C. et al Maternal and infant characteristics associated with perinatal arterial stroke in the infant. JAMA 2005; 293 (06) 723-729
• 19 Yaldizli O, Kastrup O, Wanke I, Maschke M. Basal ganglia infarction mimicking glioblastoma. Eur J Med Res 2005; 10 (09) 400-401
• 20 Sträter R, Becker S, Von Eckardstein A, Heinecke A, Gutsche S, Junker R. et al Prospective assessment of risk factors for recurrent stroke during childhood--a 5-year follow-up study. Lancet 2002; 360 (9345) 1540-1545
• 21 Ganesan V, Prengler M, McShane MA, Wade AM, Kirkham FJ. Investigation of risk factors in children with arterial ischemic stroke. Ann Neurol 2003; 53 (02) 167-173
• 22 Lanthier S, Carmant L, David M, Larbrisseau A, De Veber G. Stroke in children: the coexistence of multiple risk factors predicts poor outcome. Neurology 2000; 54 (02) 371-378
• 23 Maguire JL, deVeber G, Parkin PC. Association between iron-deficiency anemia and stroke in young children. Pediatrics 2007; 120 (05) 1053-1057
• 24 Numis AL, Fox CK. Arterial ischemic stroke in children: risk factors and etiologies. Curr Neurol Neurosci Rep 2014; 14 (01) 422
• 25 Pauley R, Mercier EL, Kumar A, Trescher WH, Mainali G. Infant Stroke Associated With Left Atrial Thrombus and Supraventricular Tachycardia. Child Neurol Open 2021; 8: X21995296
• 26 Neville K, Lo W. Sensitivity and specificity of an adult stroke screening tool in childhood ischemic stroke. Pediatr Neurol 2016; 58: 53-56
• 27 Carroll JD, Saver JL, Thaler DE, Smalling RW, Berry S, MacDonald LA. et al; RESPECT Investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368 (12) 1092-1100
• 28 Dowling MM, Ikemba CM. Intracardiac shunting and stroke in children: a systematic review. J Child Neurol 2011; 26 (01) 72-82
• 29 Brass LM, Isaacsohn JL, Merikangas KR, Robinette CD. A study of twins and stroke. Stroke 1992; 23 (02) 221-223
• 30 Frosst P, Blom HJ, Milos R, Goyette P, Sheppard CA, Matthews RG. et al A candidate genetic risk factor for vascular disease: a common mutation in methylenetetrahydrofolate reductase. Nat Genet 1995; 10 (01) 111-113
• 31 Kang S, Wu Y, Liu L, Zhao X, Zhang D. Association of the A1298C polymorphism in MTHFR gene with ischemic stroke. J Clin Neurosci 2014; 21 (02) 198-202
• 32 Sarecka-Hujar B, Kopyta I, Skrzypek M. Lack of Associations Between PAI-1 and FXIII Polymorphisms and Arterial Ischemic Stroke in Children: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2019; 25: 1076029619869500
• 33 Amlie-Lefond C, Bernard TJ, Sébire G, Friedman NR, Heyer GL, Lerner NB. et al; International Pediatric Stroke Study Group. Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study. Circulation 2009; 119 (10) 1417-1423
• 34 Given II CA, Huang-Hellinger F, Baker MD, Chepuri NB, Morris PP. Congenital absence of the internal carotid artery: case reports and review of the collateral circulation. AJNR Am J Neuroradiol 2001; 22 (10) 1953-1959
• 35 Cho JS, Kim SU, Kim HJ, Yang JH, Lee IW, Lee HJ. Successful Mechanical Thrombectomy Using Solumbra Technique In a 35-year-old Man With Achondroplasia: a case report. J Cerebrovasc Endovasc Neurosurg 2019; 21 (01) 33-39
• 36 Bowers DC, Liu Y, Leisenring W, McNeil E, Stovall M, Gurney JG. et al Late-occurring stroke among long-term survivors of childhood leukemia and brain tumors: a report from the Childhood Cancer Survivor Study. J Clin Oncol 2006; 24 (33) 5277-5282
• 37 Children's Oncology Group. Long-Term Follows-Up Guidelines for Survivors of Childhood, Adolescence, and Young Adult Cancer. Arcadia, CA: Children's Oncology Group; 2008
• 38 Wraige E, Hajat C, Jan W, Pohl KR, Wolfe CD, Ganesan V. Ischaemic stroke subtypes in children and adults. Dev Med Child Neurol 2003; 45 (04) 229-232
• 39 Vitulli F, Spennato P, Cicala D, Mirone G, Scala MR, Cinalli G. Acute ischemic stroke secondary to ventriculoperitoneal shunt dysfunction in a child with Moyamoya syndrome. Surg Neurol Int 2022; 13: 306