Kevin O’Connor, MD

Sundelin HEK, Walås A, Söderling J, Bang P, Ludvigsson JF. Long-Term Mortality in Children With Ischemic Stroke: A Nationwide Register-Based Cohort Study. Stroke. 2021.

Having recently explored post-stroke epilepsy in children, Sundelin et al. now examine mortality following pediatric stroke (<18 years of age). They identified children who had an ischemic stroke (n=1,327) along with matched controls (n=13,269) using several registers of the Swedish population (1969-2016). Of the 1,327 pediatric strokes, 343 (25.8%) were perinatal strokes and 984 were (74.2%) ischemic, which also included cerebral venous sinus thrombosis (CVST) as it could not be differentiated from ischemic stroke in the registers.

Pediatric ischemic stroke was associated with increased mortality beyond one week of follow-up from stroke (HR=10.8 [95% CI, 8.1–14.3]). Mortality remained increased past one year (HR=7.7 [95% CI, 5.6–10.7]) and past 20 years (HR=3.9 [95% CI, 2.1–7.1]). The highest risk for mortality was between one week and 6 months (HR=43.3 [95% CI, 17.8–105.3]). Overall mortality risk was elevated for both perinatal stroke (≤28 days; HR=7.0 [95% CI, 3.4–14.7]) and childhood stroke (>28 days of age; HR=11.6 [95% CI, 8.5–15.8]) without a statistically significant difference between the two. Notably, females (HR=16.7 [95% CI, 10.2–27.4]) had a statistically significant (P=0.03) higher mortality risk than males (HR=8.5 [95% CI, 6.0–12.1]).

Among children with ischemic stroke who survived at least one year, there was increased mortality from endocrine/nutritional/metabolic disease (HR=49.2 [95% CI, 5.7–420.8]), neurological disease (HR=29.9 [95% CI, 12.7–70.3]), cancers (HR=6.5 [95% CI, 2.6–15.9]), and cardiovascular disease (HR=6.2 [95% CI, 1.8–22.2]). Siblings of pediatric stroke patients had increased mortality risk (HR=1.52 [95% CI, 1.09-2.11]).

This study reveals a higher mortality risk for pediatric ischemic stroke compared to previously reported adult ischemic stroke mortality risk of 1.6-4.2 in elderly adult patients with comorbid conditions. Increased mortality among children following ischemic stroke may reflect a number of factors including underappreciation of pediatric stroke, lack of available resources for post-stroke care, and underlying hereditary risk factors. The impact of hereditary risk factors is reflected in the increased mortality among siblings of pediatric stroke patients. Future studies may be able to delineate mortality risks between pediatric ischemic stroke, CVST, and intracerebral hemorrhage.