Recurrence unlikely in childhood cryptogenic stroke

Children with cryptogenic stroke, including that associated with previous varicella infection, are very unlikely to have a recurrence, report researchers.

Furthermore, these children have consistent clinical and imaging findings, suggesting a common cause of stroke, report Stephane Darteyre (Hôpital Gui de Chauliac, Montpellier, France) and colleagues.

The team classified children's strokes as cryptogenic even if they had a recognized stroke risk factor, such as prior varicella infection, benign upper airway infection, or anemia. All of these children were treated with oral aspirin, for an average of 1.6 years after their strokes, and none experienced recurrence during 2‑3 years of follow up.

"This study, although limited by its retrospective nature, is a simple classification that allows a relatively straightforward assessment of secondary stroke risk," says Steven Pavlakis (Maimonides Medical Center, New York, USA) in a commentary accompanying the study in Neurology.

"Over the past 10 years, multiple studies have classified pediatric stroke by neuroimaging and historical criteria, such as prior infection (both often imprecise and nonspecific), making an understanding of pediatric stroke and risk of secondary stroke often complex."

There were 63 children in the study. Among the 35 with a definite stroke etiology, the most common causes were arterial dissection, moyamoya syndrome, and cardioembolism. During follow up, 30.3% of these children had a recurrence, despite anticoagulation or antiplatelet treatment, and one child died.

Clinical presentation was similar between children with and without a clear cause of stroke, but imaging findings differed markedly. All children with cryptogenic stroke had unilateral infarcts, restricted to one arterial territory, which was the case for only about 60% of children with a clear etiology.

About 60% of children with cryptogenic stroke had arterial lesions ‑ most commonly stenosis ‑ affecting the proximal middle cerebral artery, compared with about 20% of children with an established cause of stroke. Nine children with cryptogenic stroke had prior varicella infection, but their findings did not differ significantly from those of children without a history of infection.

Also, children with cryptogenic stroke were likely to have a "stuttering" onset, with symptoms coming and going. Together, this suggests that cryptogenic stroke in children may have a "common pathophysiologic mechanism, presumably inflammatory and time-limited, involving the basal arteries of the brain," say the researchers.

In his commentary, Pavlakis observes that studies like this draw attention to the importance of the pathologic mechanism in stroke recurrence risk. "This might prove the best way to further elucidate our understanding and ultimately treatment of pediatric stroke."

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