Risk of recurrent arterial ischemic stroke in childhood: A prospective international study

Heather J. Fullerton, Max Wintermark, Nancy K. Hills, Michael M. Dowling, Marilyn Tan, Mubeen F. Rafay, Mitchell S V Elkind, A. James Barkovich, Gabrielle A. Deveber

Research output: Contribution to journalArticle

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Abstract

Background and Purpose - Published cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20%. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era. Methods - The Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review. Results - Of the 355 children, 354 survived their acute index stroke, and 308 (87%) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8% (95% confidence interval, 4.6%-10%) at 1 month and 12% (8.5%-15%) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95% confidence interval, 1.8-14). The 1-year recurrence rate was 32% (95% confidence interval, 18%-51%) for moyamoya, 25% (12%-48%) for transient cerebral arteriopathy, and 19% (8.5%-40%) for arterial dissection. Conclusions - Children with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed.

Original languageEnglish (US)
Pages (from-to)53-59
Number of pages7
JournalStroke
Volume47
Issue number1
DOIs
StatePublished - Jan 1 2016

Fingerprint

Stroke
Prospective Studies
Recurrence
Fibrinolytic Agents
Confidence Intervals
Secondary Prevention
Blood Vessels
Dissection
Interviews
Pediatrics

Keywords

  • child
  • pediatrics
  • risk factor
  • stroke
  • vaccination

ASJC Scopus subject areas

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

Cite this

Fullerton, H. J., Wintermark, M., Hills, N. K., Dowling, M. M., Tan, M., Rafay, M. F., ... Deveber, G. A. (2016). Risk of recurrent arterial ischemic stroke in childhood: A prospective international study. Stroke, 47(1), 53-59. https://doi.org/10.1161/STROKEAHA.115.011173

Risk of recurrent arterial ischemic stroke in childhood : A prospective international study. / Fullerton, Heather J.; Wintermark, Max; Hills, Nancy K.; Dowling, Michael M.; Tan, Marilyn; Rafay, Mubeen F.; Elkind, Mitchell S V; Barkovich, A. James; Deveber, Gabrielle A.

In: Stroke, Vol. 47, No. 1, 01.01.2016, p. 53-59.

Research output: Contribution to journalArticle

Fullerton, HJ, Wintermark, M, Hills, NK, Dowling, MM, Tan, M, Rafay, MF, Elkind, MSV, Barkovich, AJ & Deveber, GA 2016, 'Risk of recurrent arterial ischemic stroke in childhood: A prospective international study', Stroke, vol. 47, no. 1, pp. 53-59. https://doi.org/10.1161/STROKEAHA.115.011173
Fullerton, Heather J. ; Wintermark, Max ; Hills, Nancy K. ; Dowling, Michael M. ; Tan, Marilyn ; Rafay, Mubeen F. ; Elkind, Mitchell S V ; Barkovich, A. James ; Deveber, Gabrielle A. / Risk of recurrent arterial ischemic stroke in childhood : A prospective international study. In: Stroke. 2016 ; Vol. 47, No. 1. pp. 53-59.
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abstract = "Background and Purpose - Published cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20{\%}. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era. Methods - The Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review. Results - Of the 355 children, 354 survived their acute index stroke, and 308 (87{\%}) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8{\%} (95{\%} confidence interval, 4.6{\%}-10{\%}) at 1 month and 12{\%} (8.5{\%}-15{\%}) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95{\%} confidence interval, 1.8-14). The 1-year recurrence rate was 32{\%} (95{\%} confidence interval, 18{\%}-51{\%}) for moyamoya, 25{\%} (12{\%}-48{\%}) for transient cerebral arteriopathy, and 19{\%} (8.5{\%}-40{\%}) for arterial dissection. Conclusions - Children with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed.",
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