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Immunotherapy for arterial ischaemic stroke in childhood: a systematic review
  1. Hannah B Edwards1,
  2. Andrew A Mallick2,
  3. Finbar J K O'Callaghan3
  1. 1School of Social and Community Medicine, University of Bristol and National Institute for Health Research (NIHR), Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West, Bristol, UK
  2. 2Department of Paediatric Neurology, University Hospitals Bristol NHS Foundation Trust, Level 6, Education and Research Centre, Bristol, UK
  3. 3Department of Clinical Neurosciences, University College London and Great Ormond Street Hospital for Children Institute of Child Health, University College London, London, UK
  1. Correspondence to Dr Finbar O'Callaghan, Head of Clinical Neurosciences Section, Rm 41, 4th Floor PUW South, Institute of Child Health, University College London, London WC1N 1EH, UK; Finbar{at}me.com

Abstract

Background There is little evidence about either prevention or treatment of childhood arterial ischaemic stroke (AIS). However, drugs that regulate the immune and inflammatory response could theoretically prevent occurrence or recurrence of AIS. Additionally, as an acute treatment, they may limit the neurological damage caused by AIS. Here, we systematically review the evidence on the use of immunotherapy in childhood AIS.

Design A systematic review of publications in databases Embase and Medline from inception. All types of evidence were included from trials, cohorts, case–control and cross-sectional studies and case reports.

Results 34 reports were included: 32 observational studies and 2 trials. Immunotherapy was used in two key patient groups: arteriopathy and acute infection. The majority were cases of varicella and primary angiitis of the central nervous system. All three cohorts and 80% of the case studies were treated with steroids. Recurrence rates were low. Analytical studies weakly associated steroids with lower odds of new stroke and neurological deficits, and better cognitive outcomes in the context of Moyamoya disease and tuberculosis.

Conclusions Immunotherapies are used in children with AIS, mainly as steroids for children with arteriopathy. However, there is currently little robust evidence to either encourage or discourage this practice. There is weak evidence consistent with the hypothesis that in certain children at risk, steroids may both reduce the risk of occurrent/recurrent stroke and enhance neurological outcomes. As the potential benefit is still uncertain, this indicates that a trial of steroids in childhood AIS may be justified.

  • Evidence Based Medicine
  • Neurology
  • Immunotherapy
  • Arterial Ischaemic Stroke
  • Steroids

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Footnotes

  • Contributors FJKO conceived the idea for the review and supervised all aspects of the work. HBE, AAM and FJKO formulated the search strategy and design of the review. HBE carried out the search, screening, data extraction, analysis and drafted the manuscript. FJKO and AAM contributed to the draft of the manuscript, and all authors approved the final version.

  • Funding This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Development Grants programme (RP-PG-1209-10022). HE's time was also supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West) at University Hospitals Bristol NHS Foundation Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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