Download PDF
Neuropediatrics 2021; 52(04): 294-301
DOI: 10.1055/s-0041-1728773
Original Article

Arterial Ischemic Stroke—Peculiarities of Clinical Presentation and Risk Factors in Indian Children

Jatinder Singh Goraya 
1   Division of Pediatric Neurology, Department of Pediatrics, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
,
Shivankshi Berry
1   Division of Pediatric Neurology, Department of Pediatrics, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
,
Amandeep Kaur
1   Division of Pediatric Neurology, Department of Pediatrics, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
,
Gagandeep Singh
1   Division of Pediatric Neurology, Department of Pediatrics, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

There are not enough recent studies on arterial ischemic stroke (AIS) in Indian children. We retrospectively reviewed data on 95 children (69 boys), aged 3 months to 17 years, with AIS. Focal signs were noted in 84 (88%) with hemiparesis in 72 (76%). Diffuse signs were present in 33 (35%) with fever in 22 (23%), altered mental status in 20 (21%), and headache in 12 (13%). Seizures occurred in 29 (31%) children. Arteriopathy was observed in 57 (60%) children with mineralizing lenticulostriate vasculopathy (mLSV) in 22 (23%) being the most common, followed by moyamoya in 14 (15%), arterial dissection in 9 (10%), and focal cerebral arteriopathy (FCA) in 8 (8%). Preceding head/neck trauma was present in 27 (28%) children: 23 had minor head trauma (MHT), 3 neck trauma, and 1 unspecified. Other common risk factors (RFs) were iron deficiency in 10 children, homocysteinemia in 8 children, and tuberculous meningitis in 5 children. Complete or nearly complete recovery occurred in 42 (44%). Nine children developed epilepsy and five cognitive and language disability. Stroke recurrences occurred in nine children. Overall, arteriopathies accounted for majority of the cases of childhood AIS in our study with mLSV and moyamoya being the most frequent. Compared with data from Western countries, FCAs, postvaricella arteriopathy, and arterial dissections were less common. Of the nonarteriopathic RFs, MHT, iron deficiency, homocysteinemia, and neuroinfections were most frequent in our cohort in contrast to cardioembolic diseases and inherited procoagulant conditions, which are common in developed countries.

Keywords

arterial ischemic stroke - children - arteriopathy - iron deficiency - mineralizing lenticulostriate vasculopathy - homocysteinemia

Authors' Contribution

J.S.G. conceptualized the study, reviewed the literature, and wrote the initial and final drafts. S.B. collected the data and helped writing initial draft. A.K. and G.S. were involved in data collection, literature search, and revisions of manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.


Note

Ethical Approval was approved by institutional ethical review board.




Publication History

Received: 29 May 2020

Accepted: 11 February 2021

Article published online:
08 June 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Lynch JK, Hirtz DG, DeVeber G, Nelson KB. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Pediatrics 2002; 109 (01) 116-123
    CrossrefPubMedGoogle Scholar
  • 2 deVeber G. Arterial ischemic strokes in infants and children: an overview of current approaches. Semin Thromb Hemost 2003; 29 (06) 567-573
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Mackay MT, Wiznitzer M, Benedict SL, Lee KJ, Deveber GA, Ganesan V. International Pediatric Stroke Study Group. Arterial ischemic stroke risk factors: the International Pediatric Stroke Study. Ann Neurol 2011; 69 (01) 130-140
    CrossrefPubMedGoogle Scholar
  • 4 Janaki S, Baruah JK, Jayaram SR, Saxena VK, Sharma SH, Gulati MS. Stoke in the young: a four-year study, 1968 to 1972. Stroke 1975; 6 (03) 318-320
    CrossrefPubMedGoogle Scholar
  • 5 Nagaraja D, Verma A, Taly AB, Kumar MV, Jayakumar PN. Cerebrovascular disease in children. Acta Neurol Scand 1994; 90 (04) 251-255
    CrossrefPubMedGoogle Scholar
  • 6 Makhija S, Aneja S, Tripathi RP, Narayan S. Etiological profile of stroke and its relation with prothrombotic states. Indian J Pediatr 2008; 75 (06) 579-584
    CrossrefPubMedGoogle Scholar
  • 7 Kalita J, Goyal G, Misra UK. Experience of pediatric stroke from a tertiary medical center in North India. J Neurol Sci 2013; 325 (1-2): 67-73
    CrossrefPubMedGoogle Scholar
  • 8 Patra C, Sarkar S, Guha D, Dasgupta MK. Clinico-etiological profile of childhood stroke in a Tertiary Care Hospital in Eastern India. J Neurosci Rural Pract 2015; 6 (04) 515-519
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 deVeber GA, Kirton A, Booth FA. et al. Epidemiology and outcomes of arterial ischemic stroke in children: the Canadian Pediatric Ischemic Stroke Registry. Pediatr Neurol 2017; 69: 58-70
    CrossrefPubMedGoogle Scholar
  • 10 Goraya JS, Berry S, Saggar K, Ahluwalia A. Stroke after minor head trauma in infants and young children with basal ganglia calcification: a lenticulostriate vasculopathy?. J Child Neurol 2018; 33 (02) 146-152
    CrossrefPubMedGoogle Scholar
  • 11 Lee EH, Yum M-S, Ko T-S. Risk factors and clinical outcomes of childhood ischemic stroke in a single Korean tertiary care center. J Child Neurol 2012; 27 (04) 485-491
    CrossrefPubMedGoogle Scholar
  • 12 Deng Y, Wang Y, Yang W. et al. Risk factors and imaging characteristics of childhood stroke in china. J Child Neurol 2015; 30 (03) 339-343
    CrossrefPubMedGoogle Scholar
  • 13 Mallick AA, Ganesan V, Kirkham FJ. et al. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol 2014; 13 (01) 35-43
    CrossrefPubMedGoogle Scholar
  • 14 Per H, Unal E, Poyrazoglu HG. et al. Childhood stroke: results of 130 children from a reference center in Central Anatolia, Turkey. Pediatr Neurol 2014; 50 (06) 595-600
    CrossrefPubMedGoogle Scholar
  • 15 Ganesan V, Prengler M, McShane MA, Wade AM, Kirkham FJ. Investigation of risk factors in children with arterial ischemic stroke. Ann Neurol 2003; 53 (02) 167-173
    CrossrefPubMedGoogle Scholar
  • 16 Lingappa L, Varma RD, Siddaiahgari S, Konanki R. Mineralizing angiopathy with infantile basal ganglia stroke after minor trauma. Dev Med Child Neurol 2014; 56 (01) 78-84
    CrossrefPubMedGoogle Scholar
  • 17 Yang FH, Wang H, Zhang JM, Liang HY. Clinical features and risk factors of cerebral infarction after mild head trauma under 18 months of age. Pediatr Neurol 2013; 48 (03) 220-226
    CrossrefPubMedGoogle Scholar
  • 18 Fidan E, Cummings DD, Manole MD. A case of lenticulostriate stroke due to minor closed head injury in a 2-year-old child: role of mineralizing angiopathy. Pediatr Emerg Care 2018; 34 (12) e233-e235
    CrossrefPubMedGoogle Scholar
  • 19 Cecchini C, Iqbal S, Murnick J. Case 4: Stroke after minor head trauma in an otherwise healthy 18-month-old boy. Pediatr Rev 2018; 39 (06) 313-315
    CrossrefPubMedGoogle Scholar
  • 20 Khalid MT, Chan DWS, Tan EEK. et al. Right middle cerebral artery infarct after minor head trauma in an infant: case report and literature review. Int J Pediatr Adolesc Med 2019; 6 (03) 121-124
    CrossrefPubMedGoogle Scholar
  • 21 Toelle SP, Avetisyan T, Kuyumjyan N, Sukhudyan B, Boltshauser E, Hackenberg A. Infantile basal ganglia stroke after mild head trauma associated with mineralizing angiopathy of lenticulostriate arteries: an under recognized entity. Neuropediatrics 2018; 49 (04) 262-268
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Sarna A, Porwal A, Ramesh S. et al. Characterisation of the types of anaemia prevalent among children and adolescents aged 1-19 years in India: a population-based study. Lancet Child Adolesc Health 2020; 4 (07) 515-525
    CrossrefPubMedGoogle Scholar
  • 23 Kim JS. Moyamoya disease: epidemiology, clinical features, and diagnosis. J Stroke 2016; 18 (01) 2-11
    CrossrefPubMedGoogle Scholar
  • 24 Amlie-Lefond C, Bernard TJ, Sébire G. et al; International Pediatric Stroke Study Group: Predictors of cerebral arteriopathy in children with arterial ischemic stroke: results of the International Pediatric Stroke Study. Circulation 2009; 119 (10) 1417-1423
    CrossrefPubMedGoogle Scholar
  • 25 Askalan R, Laughlin S, Mayank S. et al. Chickenpox and stroke in childhood: a study of frequency and causation. Stroke 2001; 32 (06) 1257-1262
    CrossrefPubMedGoogle Scholar
  • 26 Jauhari P, Sankhyan N, Khandelwal N, Singhi P. Childhood basal ganglia stroke and its association with trivial head trauma. J Child Neurol 2016; 31 (06) 738-742
    CrossrefPubMedGoogle Scholar
  • 27 Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009; 8 (07) 668-678
    CrossrefPubMedGoogle Scholar
  • 28 Fullerton HJ, Johnston SC, Smith WS. Arterial dissection and stroke in children. Neurology 2001; 57 (07) 1155-1160
    CrossrefPubMedGoogle Scholar
  • 29 Maguire JL, deVeber G, Parkin PC. Association between iron-deficiency anemia and stroke in young children. Pediatrics 2007; 120 (05) 1053-1057
    CrossrefPubMedGoogle Scholar
  • 30 Hartfield DS, Lowry NJ, Keene DL, Yager JY. Iron deficiency: a cause of stroke in infants and children. Pediatr Neurol 1997; 16 (01) 50-53
    CrossrefPubMedGoogle Scholar
  • 31 Munot P, De Vile C, Hemingway C, Gunny R, Ganesan V. Severe iron deficiency anaemia and ischaemic stroke in children. Arch Dis Child 2011; 96 (03) 276-279
    CrossrefPubMedGoogle Scholar
  • 32 Azab SFA, Abdelsalam SM, Saleh SHA. et al. Iron deficiency anemia as a risk factor for cerebrovascular events in early childhood: a case-control study. Ann Hematol 2014; 93 (04) 571-576
    CrossrefPubMedGoogle Scholar
  • 33 Sirachainan N, Tapanapruksakul P, Visudtibhan A. et al. Homocysteine, MTHFR C677 T, vitamin B12, and folate levels in Thai children with ischemic stroke: a case-control study. J Pediatr Hematol Oncol 2006; 28 (12) 803-808
    CrossrefPubMedGoogle Scholar
  • 34 Erol M, Gayret OB, Yigit O, Serefoglu Cabuk K, Toksoz M, Tiras M. A case of homocystinuria misdiagnosed as moyamoya disease: a case report. Iran Red Crescent Med J 2016; 18 (04) e30332
    CrossrefPubMedGoogle Scholar
  • 35 Bhoi SK, Naik S, Dubey D, Kalita J, Misra UK. Moyamoya syndrome in a child with methyl tetrahydrofolate reductase mutation. Neurol India 2017; 65 (06) 1408-1409
    CrossrefPubMedGoogle Scholar
  • 36 Lee YY, Lin KL, Wang HS. et al. Craniocervical arterial dissection: a cause of childhood arterial ischemic stroke in Taiwan. J Formos Med Assoc 2010; 109 (02) 156-162
    CrossrefPubMedGoogle Scholar
  • 37 Luo H, Liu B, Hu J, Wang X, Zhan S, Kong W. Hyperhomocysteinemia and methylenetetrahydrofolate reductase polymorphism in cervical artery dissection: a meta-analysis. Cerebrovasc Dis 2014; 37 (05) 313-322
    CrossrefPubMedGoogle Scholar
  • 38 Akar N, Akar E, Özel D, Deda G, Sipahi T. Common mutations at the homocysteine metabolism pathway and pediatric stroke. Thromb Res 2001; 102 (02) 115-120
    CrossrefPubMedGoogle Scholar
  • 39 Wadia RS, Edul NC, Bhagat S. et al. Hyperhomocysteinaemia and vitamin B12 deficiency in ischaemic strokes in India. Ann Indian Acad Neurol 2004; 7 (02) 387-392
    PubMedGoogle Scholar
  • 40 Kumawat BL, Sharma CM, Shah MJ, Panchal MA. Hyperhomocysteinemia and vitamin B12 deficiency as a risk factor for ischemic stroke: a case–control study from Northwestern India. Indian J Health Sci Biomed Res 2018; 11 (03) 228-233
    CrossrefPubMedGoogle Scholar