Lack of Recurrence and Progressive Arteriopathy among Children with Cryptogenic Stroke

Dr S. DARTEYRE, MD, MSc1

Dr S. CHABRIER, MD, MSc1

Pr. F. RIVIER, MD, PhD2

1. CHU Saint Etienne. 2. CHU MontpellierResearch Group on Thrombosis, EA 3065

National Centre for Pediatric Stroke

Lecture Plan

• Classification of Stroke in Young Adults.• Classical Clinical Histories in Children.• Study Hypothesis.• Study Methods.• Study Results.• Discussion.• Conclusion.

A Classical Dichotomy

• Adult Stroke Background.• Stroke in Young Adults (< 40 y).• Symptomatic Forms (dissections…).• Cryptogenic Forms (at least 40%).• Connecting Departments.

And Classical Histories…

Lea, 5 years old. Right hemiparesis. Lateral Lenticulo Striate (LLS).M1 stenosis. Varicella. Aspirin. Good Recovery.

Study Hypothesis

• Are Childhood Cryptogenic Strokes doing Better than Symptomatic Ones ?

Study Methods (1)

• Age: 3 months to 16 years.• Arterial Ischemic Strokes (AIS) Bernard Stroke 2012

• Transient Ischemic Attacks (TIA) Albers NEJM 2002

• Classification of Cerebral Arteriopathies Bernard Stroke 2012, Sébire Lancet 2006

– Dissections– Transient Cerebral Arteriopathies (TCA)– Post-Varicella Arteriopathies (PVA)– Moya-moya, others…

Study Methods (2)

Symptomatic

Clear Mechanism

Cryptogenic

No Clear Mechanism After Extensive Work-Up

Risk Factors Only

Altieri Stroke 2009

Study Methods (3)

• Inclusion: age, AIS or TIA.• Retrospective, single center, ICD-9 and 10.• Primary Endpoints:– Recurrences: new AIS/TIA 2 w after index stroke– Death.– NIS.

• Secondary Endpoints:– Radiological Evolution of Arteriopathies.

Lower extremity motor impairmentabsent = 0light = 1moderate = 2severe = 3 Movement disorderspresent = 1absent = 0 Behaviour troublespresent = 1absent = 0 Epilepsyabsent = 0benign = 1severe = 2

Education/Schoolnormal = 0school support = 1institution = 2 Home supportnecessary = 1not necessary = 0 Language disordersabsent = 0moderate = 1severe = 2 Upper extremity motor impairmentabsent = 0light = 1moderate = 2severe = 3

LONG-TERM NEUROLOGICAL IMPAIRMENT SCORE (NIS)

TOTAL = / 150 - 5: minor impairment5 - 10: moderate impairment10 - 15: severe impairment

Results (1)

Results (2)

SYMPTOMATIC ( N=35)• Multiple AIS*• Bilateral*• Posterior Infarcts*• Sylvian Superficial*• Vertebral stenosis*• Anticoagulation/Aspirin*• Death = 1• Recurrence 30%*• Mean NIS 4.2*• Progressive Arteriopathies*

CRYPTOGENIC (N=28)• Single AIS*• Unilateral*• Anterior Infarcts*• Sylvian Deep (LLS)*• M1 focal stenosis*• Aspirin alone*• Death = 0• Recurrence 0%*• Mean NIS 2.4*• Non-Progressive Arteriopathies*

*p < 0.05

* P < 0.05

Discussion

• Childhood Cryptogenic Strokes Do Better Than Symptomatic Ones

• Recurrences In Literature: 5-7% IdiopathicSträter 2002, Fullerton 2007

• Definition (timing) of Recurrences +++• PVA: symptomatic or cryptogenic ?• Follow-Up• Retrospective = Biases

Conclusion

• Childhood Cryptogenic Stroke.• Multiple Risk Factors.• Aspirin.• To be Validated with EBM.

• Evidence – Ethics – Common Sense

Secondary Prevention for AISEuropean Survey

stephane.darteyre@chu-st-etienne.fr

stefdart@gmail.com