Aims Paediatric acute ischaemic stroke (AIS) is a neurological emergency. The Royal College of Physician guidelines (2004) focus on imaging and basic treatment. The understanding of AIS has improved therefore we aimed to investigate current management.
Methods Notes of children (<17 years) with AIS or arterial dissection requiring brain rehabilitation (2010–15) from two tertiary centres were reviewed. Information collected included: investigations requested, management and outcome using the Glasgow Outcome Scale (GOS). Blood investigations were grouped: ‘Routine’ included FBC, U and E, LFT, bone profile, glucose, CRP; ‘Basic clotting profile’ included PT, APTT, fibrinogen;‘Advanced clotting profile’ included d-dimer, lipids, factor V Leiden, factor VIII, Von Willebrand, Protein C and S, APC; ‘Full vasculitis screen’ included ESR, CRP, lupus anticoagulant, antiphospholipid, ANA, ANCA, ds-DNA, ENA, TPO, anticardiolipin, antithrombin III, lipoprotein, homocysteine, immunoglobulins.
Results Forty-three cases (28 boys) were identified. The median age was 4 years 11 months (5 days – 16 years 5 months). Aetiologies included: 14 unknown; 8 infectious (5 varicella; 3 meningitis); 7 secondary to cardiac pathology; 7 Moya Moya disease; 5 arterial dissection; 1 fibromuscular dysplasia, 1 sickle cell anaemia. All had MRI [27 (63%) also had MRA] in keeping with the guideline although there was a>48 hour delay in imaging in three (7%) due to atypical presentation. Bloods undertaken included: Routine 43 (100%); Basic clotting 35 (81%); Advanced clotting 20 (46.5%); Full vasculitis screen 12 (28%); prothrombin gene mutation 14 (32.5%) (all negative). Thirty-two received anticoagulation appropriately (aspirin 27; other 5). None received inappropriate anticoagulation. Eleven (25%) had neurological sequelae with the median (range) GOS (n=32) being 5 (3–5).
Conclusions The incidence of stroke in the 2 catchment areas was 2.1/100 000. No patients died but a quarter had neurological sequelae. No cause was identified in a third of cases but a wide variation in the investigations undertaken existed: less than a third had a vasculitis and half had an advanced clotting screen. Imaging and anticoagulation were in keeping with current guidelines. New AIS guidelines to include investigations for treatable causes such as vasculitis are needed. This may help determine more aetiologies and improve management.
Royal College of Physicians. Stroke in Childhood: clinical guidelines for diagnosis, management and rehabilitation. 2004. Available from: [http://www.rcpch.ac.uk/system/files/protected/page/RCP%20-%20Stroke%20in%20childhood%2020015_0.pdf]
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