Childhood arterial ischaemic stroke (AIS) is a heterogeneous disorder, with morbidity in 2/3rd of survivors and recurrence in 10%. Current clinical guidelines recommend a wide range of investigations for cerebrovascular, metabolic and thrombotic risk factors. This is expensive and it is unclear how often a positive result alters clinical management.
Aim To investigate the (i) diagnostic yield and (ii) impact on treatment of a extensive panel of investigations for childhood AIS risk factors in patients seen in a single tertiary paediatric neurology unit.
Methods Children (>28 days old) with radiologically confirmed AIS seen at our centre 2000 – 2011 were eligible. Since 2000 local guidelines have recommended a standard panel of investigations1 and patients have been managed according to national clinical guidelines. Results and impact on treatment were abstracted from case notes.
Results Data from 51 children was reviewed (24 male, age 6 months – 16 years, median 5 years). Cerebrovascular imaging and screening for prothrombotic disorders was most comprehensive; metabolic and infection investigations were largely incomplete.
8/51 patients had prothombotic risk factors (4 MTHFR homozygous, 1 positive lupus anticoagulant, 2 protein S deficient, 1 Factor V Leiden heterozygous) but these did not alter clinical management. 1 patient was anaemic (requiring blood transfusion) and another had hypercholesterolaemia (treated with statins). Evidence of past infection was frequently identified but did not alter management. In contrast, magnetic resonance angiography (of the circle of Willis and cervical vasculature) was abnormal in 41/51, and influenced onward management in 43 cases. Echocardiography was abnormal in 11/35 available reports. 1 patient had infective endocarditis to which their stroke was attributed and 8 patients had congenital structural abnormalities of varying significance.
Conclusions Laboratory investigations for paediatric AIS patients have a low diagnostic yield and rarely alter treatment decisions. Cerebrovascular imaging is often fruitful and is key to management. These data may contribute to prioritisation of health care spending related to the investigation of childhood AIS. Wider laboratory evaluation may, however, be indicated in individual cases, dependent on the clinical circumstances.
Kirkham FJ. Stroke in childhood. Arch Dis Child. 1999; 81: 85–89.