Neal S. Parikh, MD

Fullerton HJ, Wintermark M, Hills NK, Dowling MM, Tan M, Rafay MF, et al. Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study. Stroke. 2015

Citing a paucity of contemporary pediatric stroke recurrence risk data, Fullerton and colleagues conducted a prospective study to measure recurrent stroke rates and risk factors for recurrent strokes in children.

Patients were enrolled from 2010 to 2014 from 37 centers across 9 countries for the Vascular effects of Infection in Pediatrics (VIPS) protocol. Strokes were classified as having definite, possible or no arteriopathy and then further subdivided into transient cerebral arteriopathy, arterial dissection, moyamoya, vasculitis, or other. Strokes without arteriopathy were classified as idiopathic, cardioembolic or other. The researchers also collected data regarding infections in the 3 weeks prior to the index stroke and patients’ vaccination statuses.

355 children were enrolled and followed over a median of 2 years. 87% were treated with antithrombotic medications. There were 42 recurrent strokes, all ischemic, at a median of 23 days from index stroke. 6.8% had 1-month recurrence; 12% had 1-year recurrence.

The only predictor of recurrent stroke was definite arteriopathy, which increased the hazard of recurrence by five-fold compared to idiopathic index stroke. 21% of children with index stroke due to definite arteriopathy experienced a recurrent stroke. The highest recurrence rate was for children with moyoamoya disease. 75% of recurrent strokes occurred within 12 weeks of index stroke. Of note, though these authors previously showed recent infection and unvaccinated status to be associated with incident stroke, these variables were not associated with recurrent stroke risk.

The high stroke recurrence rate in children with arteriopathy is remarkable. As the authors conclude, arteriopathy – particularly forms in children such as transient cerebral arteriopathy and moyamoya disease – may have unique pathophysiologic underpinnings and therefore treatments.