Pediatric cardiac disease is associated with an increased risk for arterial ischemic stroke (AIS) following cardiac procedures, according to a study published in Pediatric Neurology. Stroke may be triggered by prothrombotic or inflammatory conditions among this vulnerable population.
This study included 672 newborns or children suffering from AIS between birth and age 19, all of whom had cardiac disease preceding the AIS episode. Enrollment occurred between 2003 and 2014 as part of the International Pediatric Stroke Study. Study researchers collected data on risk factors for stroke, which included prothrombotic states, severe systemic illness, coagulopathy among family members, and cardiac disease.
Outcomes included AIS occurring within 3 days of cardiac procedures (periprocedural group: n=177; 26%), as well as spontaneous AIS occurring after 3 days (spontaneous group: n=495; 74%). Categorical variables were compared between the groups using chi-squared or Fisher’s exact tests, while the t-test was used to compare normally distributed continuous variables.
Among non-newborns, spontaneous AIS occurred at a median age of 4.2 years (interquartile range [IQR] 0.97-12.4), whereas periprocedural stroke occurred at a median age of 2.4 years (IQR 0.35-6.1 years), marking a significant differentiation by age (P <.001). The presence of severe systemic illness during AIS did not differ significantly between the spontaneous group (37%) and the periprocedural group (31%; P =.17), though participants with acquired heart disease were at significantly higher risk (49%) than those with congenital heart defects (34%; P =.01).
Compared to the periprocedural group, those in the spontaneous group were more likely to have moderate to acute neurologic deficit at discharge (67% vs 33%; P =.01) and to have experienced a previous thrombotic event (16% vs 9%; P =.02). Among newborns, the periprocedural and spontaneous groups, no significant difference in terms of severe systemic illness, number and location of infarcts, or previous thrombotic events was found.
Limitations to this study included a narrow definition of periprocedural AIS, a consequent potential for underrepresentation of those affected, and the difficulty in assessing the time of stroke occurrence. Further, exclusive inclusion of participants recruited by investigators, a lack of differentiation between single ventricle statuses or cyanotic and noncyanotic heart disease, and variable post-discharge follow up may have also limited these findings.
The study researchers concluded that while many cases of cardiac-related pediatric AIS occur outside the immediate periprocedural window, “[a] high proportion of the patients in our study appeared to have an acute systemic illness as an additional trigger for the [AIS] or a prior thrombotic event.” They believe that the, “[c]hoice and duration of treatment with antithrombotic therapy was inconsistent,” and that, “[t]hese findings reflect uncertainties in optimal clinical care for a complicated and heterogeneous group; additional data [are] required to guide evidence-based management.”
Chung MG, Guilliams KP, Wilson JL, et al. Arterial ischemic stroke secondary to cardiac disease in neonates and children [published online June 27, 2019]. Pediatr Neurol. doi: 10.1016/j.pediatrneurol.2019.06.008