Arteriopathy diagnosis in childhood arterial ischemic stroke: Results of the vascular effects of infection in pediatric stroke study

Max Wintermark, Nancy K. Hills, Gabrielle A. DeVeber, A. James Barkovich, Mitchell S V Elkind, Katherine Sear, Guangming Zhu, Carlos Leiva-Salinas, Qinghua Hou, Michael M. Dowling, Timothy J. Bernard, Neil R. Friedman, Rebecca N. Ichord, Heather J. Fullerton, S. L. Benedict, C. K. Fox, W. D. Lo, M. A. Tan, M. T. Mackay, A. KirtonM. I. Hernandez Chavez, P. Humphreys, L. C. Jordan, S. M. Sultan, M. J. Rivkin, M. F. Rafay, L. Titomanlio, G. S. Kovacevic, J. Y. Yager, C. Amlie-Lefond, N. Dlamini, J. Condie, A. Yeh, R. Kneen, B. H. Bjornson, P. Pergami, L. P. Zou, J. Elbers, A. Abdalla, A. K. Chan, O. Farooq, M. J. Lim, J. L. Carpenter, S. Pavlakis, V. C. Wong, R. Forsyth

Research output: Contribution to journalArticle

67 Scopus citations

Abstract

Background and Purpose - Although arteriopathies are the most common cause of childhood arterial ischemic stroke, and the strongest predictor of recurrent stroke, they are difficult to diagnose. We studied the role of clinical data and follow-up imaging in diagnosing cerebral and cervical arteriopathy in children with arterial ischemic stroke.

Methods - Vascular effects of infection in pediatric stroke, an international prospective study, enrolled 355 cases of arterial ischemic stroke (age, 29 days to 18 years) at 39 centers. A neuroradiologist and stroke neurologist independently reviewed vascular imaging of the brain (mandatory for inclusion) and neck to establish a diagnosis of arteriopathy (definite, possible, or absent) in 3 steps: (1) baseline imaging alone; (2) plus clinical data; (3) plus follow-up imaging. A 4-person committee, including a second neuroradiologist and stroke neurologist, adjudicated disagreements. Using the final diagnosis as the gold standard, we calculated the sensitivity and specificity of each step.

Results - Cases were aged median 7.6 years (interquartile range, 2.8-14 years); 56% boys. The majority (52%) was previously healthy; 41% had follow-up vascular imaging. Only 56 (16%) required adjudication. The gold standard diagnosis was definite arteriopathy in 127 (36%), possible in 34 (9.6%), and absent in 194 (55%). Sensitivity was 79% at step 1, 90% at step 2, and 94% at step 3; specificity was high throughout (99%, 100%, and 100%), as was agreement between reviewers (=0.77, 0.81, and 0.78).

Conclusions - Clinical data and follow-up imaging help, yet uncertainty in the diagnosis of childhood arteriopathy remains. This presents a challenge to better understanding the mechanisms underlying these arteriopathies and designing strategies for prevention of childhood arterial ischemic stroke.

Original languageEnglish (US)
Pages (from-to)3597-3605
Number of pages9
JournalStroke
Volume45
Issue number12
DOIs
StatePublished - Dec 11 2014

Keywords

  • Cerebral arterial diseases
  • Pediatrics
  • Stroke
  • Transient ischemic attack

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

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    Wintermark, M., Hills, N. K., DeVeber, G. A., Barkovich, A. J., Elkind, M. S. V., Sear, K., Zhu, G., Leiva-Salinas, C., Hou, Q., Dowling, M. M., Bernard, T. J., Friedman, N. R., Ichord, R. N., Fullerton, H. J., Benedict, S. L., Fox, C. K., Lo, W. D., Tan, M. A., Mackay, M. T., ... Forsyth, R. (2014). Arteriopathy diagnosis in childhood arterial ischemic stroke: Results of the vascular effects of infection in pediatric stroke study. Stroke, 45(12), 3597-3605. https://doi.org/10.1161/STROKEAHA.114.007404