Mark N Rubin, MD

Wintermark M, Hills NK, deVeber GA, Barkovich AJ, Elkind MSV, Sear K, et al. Arteriopathy Diagnosis in Childhood Arterial Ischemic Stroke: Results of the Vascular Effects of Infection in Pediatric Stroke Study. Stroke. 2014

“You can observe a lot just by watching.”
~Yogi Berra

Thankfully, acute ischemic stroke is fairly rare in the pediatric population. However, when it occurs, arteriopathy of some kind – be it inflammatory, traumatic, or iatrogenic – is a major cause thereof. Estimates of incidence vary widely by reports, in part because of heterogeneous populations and diagnostic resources, and the inherent difficulty in diagnosing an arteriopathy in the first place. That being the case, a NIH-funded international group of pediatric investigators sought to clarify the diagnostic process by adjudicating consecutive stroke patients. They studied the test performance of diagnoses of arteriopathy based on baseline imaging alone, baseline imaging and clinical data, and the combination of baseline imaging, clinical data and follow up imaging.

Their cohort consisted of 355 cases, and 45% (161 patients) were thought to have definite (36%, 127 patients) or possible (9.6%, 34 patients) arteriopathy. As one might expect, sensitivity grew with each “step” of additional data, from 79% with baseline vascular imaging alone to 90% with both vascular imaging and clinical data and up to 94% with the former elements plus follow up imaging. Agreement was excellent at each step (κ ~ 0.8). Cases were clearly diagnosed conservatively as specificity was essentially 100% for any amount of data provided.  

The results of this study can be a bit difficult to generalize given the heterogeneity of everything from the diagnosis of arteriopathy to the clinical means of coming to that conclusion. However, and important take-away from their investigation is that “more is better” as regards difficult diagnoses. As is the case with much of clinical neurology, results of diagnostics must be contextualized within a pattern of illness to be of most use to the patient and the provider.