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(Circulation. 2006;114:2170-2177.)
© 2006 American Heart Association, Inc.

Stroke

Clinical and Radiological Recurrence After Childhood Arterial Ischemic Stroke

Vijeya Ganesan, MD; Mara Prengler, PhD; Angela Wade, PhD; Fenella J. Kirkham, MB, BCh

From the Neurosciences Unit (V.G., M.P., F.J.K.) and Centre for Paediatric Epidemiology and Biostatistics (A.W.), Institute of Child Health (University College London), London, United Kingdom.

Correspondence to Dr Vijeya Ganesan, Senior Lecturer in Paediatric Neurology, Neurology Department, Level 3 Southwood Bldg, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, United Kingdom. E-mail v.ganesan{at}ich.ucl.ac.uk

Received August 18, 2005; revision received August 8, 2006; accepted August 10, 2006.

Background— Data on rates and risk factors for clinical and radiological recurrence of childhood arterial ischemic stroke (AIS) might inform secondary prevention strategies.

Methods and Results— Consecutive Great Ormond Street Hospital patients with first AIS were identified retrospectively (1978–1990) and prospectively (1990–2000). Patients underwent repeat neuroimaging at the time of clinical recurrence or, if asymptomatic, at least 1 year after AIS. Cox and logistic regression analyses were used to explore the relationships between risk factors and clinical and radiological recurrence, respectively. A total of 212 patients were identified, of whom 97 had another prior diagnosis. Seventy-nine children had a clinical recurrence (29 strokes, 46 transient ischemic attacks [TIAs], 4 deaths with reinfarction 1 day to 11.5 years (median 267 days) later); after 5 years, 59% (95% confidence interval, 51% to 67%) were recurrence free. Moyamoya on angiography and low birth weight were independently associated with clinical recurrence in the whole group. Genetic thrombophilia was associated with clinical recurrence in previously healthy patients, independent of the presence of moyamoya. Sixty of 179 patients who had repeat neuroimaging had radiological reinfarction, which was clinically silent in 20. Previous TIA, bilateral infarction, prior diagnosis (specifically immunodeficiency), and leukocytosis were independently associated with reinfarction. Previous TIA and leukocytosis were also independently associated with clinically silent reinfarction.

Conclusions— Clinical and radiological recurrence are common after childhood AIS. The risk of clinical recurrence is increased in children with moyamoya and, in previously healthy patients, in those with genetic thrombophilia. Preexisting pathology, including immunodeficiency, and persistent leukocytosis are risk factors for radiological recurrence, which suggests a potential role for chronic infection.

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CLINICAL PERSPECTIVE

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