Arterial Ischemic Stroke Outcomes in Children: Indian Perspective.

Unlike in adults, strokes in children are rare. It is important to realize that pediatric stroke is a symptom and not the disease itself. It results due to interaction of multiple risk factors. The risk factors for stroke differ depending on the age of the child and even on location (developed or developing country) also.[1] The investigations and treatment strategies are different, depending on the risk factors in a given child. Few of the risk factors like iron deficiency anemia, mineralizing angiopathy are more common in developing countries like India.[2] Pediatric strokes are associated with long-term sequelae like recurrences, epilepsy, intellectual, and physical disabilities. The final outcomes are dependent on the size and location of the infarct, underlying risk factors of stroke and the interventions done.[3] With early and appropriate intervention, few of the long-term sequelae can be prevented (for example, use of anti-thrombotic treatment to prevent recurrences) or at least their effect on the child minimized (for example, early rigorous physiotherapy for hemiparesis and functional deficit).[1] Due to lack of awareness about pediatric strokes among pediatricians, lack of access to advanced neuroimaging facilities and interventions, the clinical profile and outcome of stroke is likely to be different in developing countries like ours. Unfortunately, we do not have many publications (hospital based or community based) on pediatric strokes from India. In this edition, a paper on long-term experience with arterial ischemic stroke in children in a single center has been published.

Few of the risk factors for arterial ischemic strokes in children are commonly seen in to our country like the mineralizing angiopathy, that typically present as strokes following minor trauma in an otherwise healthy infant/toddler.[24] It is one of the most common cause of arterial ischemic strokes in otherwise healthy children less than 5 years of age. It accounted for 24.4% (11 out of 49) in the current study. The infarcts are usually subcortical affecting the basal ganglia due to involvement of the lenticulostriate arteries. Recently, its association with perinatal infections has been suggested.[5] This could be one of the reasons why it has been described mainly from developing countries who have poor perinatal care. Many of these children recover completely over a period of few weeks without specific treatment. A minority of them can be left with sequelae like hemiparesis or dystonia. Because there is sparing of cortex in this condition, there is usually no long-term epilepsy or cognitive impairment in these children. If steps to prevent further trauma are not taken, there is chance of recurrence. They are usually diagnosed on a plain computed tomography of the brain with coronal/sagittal reconstruction. MRI of brain may miss the diagnosis as it shows only basal ganglia infarcts and MR angiography can be normal. These children usually do not need expensive and extensive work-up like prothrombotic work-up, vessel wall imaging, intensive care admissions, and anti-thrombotic treatments. These facts can only be brought out when we have more publications on this topic.

The location of the infarcts can suggest probable risk factors. While infarcts in the anterior circulation in children beyond 3–4 years of age are usually secondary to arteriopathies like focal cerebral arteriopathy and moya–moya syndromes that can be easily diagnosed by noninvasive imaging techniques like MR angiography or CT angiography, infarcts in the posterior circulation are typically due to arteriopathies secondary to dissection of arteries.[3] They need special invasive methods like digital subtraction angiography or more sophisticated vessel wall imaging with contrast and detailed imaging of the neck also. Knowing the underlying nature of arteriopathy helps deciding treatment. While moya–moya syndrome patients usually need surgery with anti-platelet drugs, in focal cerebral arteriopathy use of anti-platelet drugs for 2–5 year suffices. Arterial dissection, especially if extracranial, needs anticoagulation for at least 6 months.[1]

As is evident in the present study, the presence of seizures, cortical localization of infarct, and recurrences were associated with poor long-term cognitive outcomes. Early, daily intensive physiotherapy in the form of constraint-induced movement therapy, speech therapy, and occupational therapy can help to minimize the functional deficit associated with pediatric strokes. Depending on the underlying risk factors, most children need anti-thrombotic treatment to prevent recurrences. While children with epilepsy mostly respond to anti-seizure medications, some children who have medically refractory epilepsy and are also associated with poor outcomes can be good candidates for epilepsy surgery like functional hemispherotomy. This intervention can reduce the anti-seizure drug burden and provide good long-term outcomes.

For rare diseases like pediatric strokes, there is a need to collaborate and collate the data from different centers in India also like the International Pediatric Stroke Study Group (IPSS). We can use standardized definitions (Childhood AIS Standardized Classification and Diagnostic Evaluation-CASCADE given by IPSS), case record forms, imaging, treatment, outcome measures (pediatric stroke outcome measures scales), and follow-up protocols so that we can have robust data from our country which will help the pediatricians to treat children with strokes.[67] Such studies can also guide judicious use of appropriate investigations and therapeutic interventions in resource poor countries like India.

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Competing interests

There are no conflicts of interest.