Major Finding: Children who have had a stroke face a 13% risk for a recurrent stroke.
Data Source: Prospective, single-center study of 90 children followed after their index stroke during 2003–2009.
Disclosures: Dr. Ichord serves on the clinical event committee for the pivotal U.S. trial of the Berlin Heart ventricular assist device. She said that none of her associates had any disclosures.
SAN ANTONIO — Children who have had a stroke face a 13% risk for a second stroke, based on prospective follow-up of 93 children.
Half of the recurrences occurred before the index stoke was recognized and secondary prevention treatment begun, a finding that highlights the need for improved early recognition of strokes in children, Dr. Rebecca N. Ichord said at the International Stroke Conference.
“Delays in diagnosis may adversely affect recurrence risk by delaying the start of secondary preventive treatment,” said Dr. Ichord, a pediatric neurologist and director of the pediatric stroke program at The Children's Hospital of Philadelphia.
She acknowledged, however, that no proven treatments exist for secondary stroke prevention in children. “We use the same treatments in children that we use in adults, but we don't know” how well they work. “We use aspirin, warfarin, low-molecular-weight heparin, and we do surgical interventions, but we don't know how long we need to anticoagulate, or whether warfarin is better than aspirin. We are just beginning to get accurate and prospective data on recurrence risk, then we can start analyzing risk factors, and then we can start to test risk-stratified treatment in clinical trials.”
Her study involved 93 children who came to The Children's Hospital for stroke assessment. Their average age was 8 years; age ranged from neonatal to 18 years. Two-thirds were boys. The most common risk factors for stroke were vasculopathy in 37 followed by a cardioembolic cause in 26.
Three of the 93 patients died from their underlying disease soon after the initial stroke; follow-up data were available for 85 of the remaining 90 for a median of 16 months, ranging from 1 to 72 months. During follow-up, 12 children had recurrent strokes (13% of the initial 93), including one child with two recurrences. Recurrent strokes were defined as episodes that occurred at least 24 hours after the index stroke and were radiologically distinct events.
Six children had their recurrence before the index stroke was identified and prophylaxis begun. The other six children had their second stroke an average of 9 days following confirmation of the index episode and prophylaxis had begun, ranging from 4 to 96 days. Ten of the recurrences occurred in children with vasculopathy as the primary cause of their index event, and two had index events that involved a cardioembolic trigger.
In patients whose index stroke was recognized, all but two received antiplatelet treatment, anticoagulant treatment, or both. Selected patients also received surgical interventions such as revascularization or repair of a patent foramen ovale.
“The pathogenesis of recurrences is complex,” with some cases involving new vessel injuries, Dr. Ichord said at the conference, which was sponsored by the American Heart Association. Her current practice is to continue prophylactic antithrombotic treatment for 1–2 years, after which she tells families that the ongoing risk of recurrence is very low and that prophylaxis can probably be stopped.