EDITORIAL
Big strokes for little folks
Doris A. Trauner, MD Warren Lo, MD
Correspondence to Dr. Trauner: [email protected] Neurology® 2014;82:742–743
Pediatric stroke occurs with an incidence of 2–13/ 100,000 and may account for major neurologic impairment in stroke survivors. Outcomes vary and numerous factors may account for that variability. Such factors include age at stroke occurrence, location and size of the affected brain regions, presence or absence of seizures, and etiology. Because of these variables, practitioners have limited data upon which to provide families with accurate prognostic information. In this issue of Neurology®, Studer et al.1 used a population-based approach to identify factors influencing outcome after pediatric stroke. Using the Swiss Neuropediatrics Stroke Registry, they identified all children diagnosed with stroke between 1 month and 16 years of age since 2000. Ninety-nine children were available for study and received neurologic and psychological testing. The authors found that younger age at onset, presence of seizures, lesion location that included both cortical and subcortical regions, and severe neurologic impairment were risk factors for poor cognitive outcome. This study confirms and extends earlier work that found similar results in pediatric stroke patients.2–4 Of note, 40% had no functional deficit and 70% had modified Rankin Scale (mRS) scores #2, which suggests that a substantial number of children had good outcomes, similar to another study that reported long-term neurologic outcome.5 This study is important in that it is one of the largest cohorts reported to date for which the patients were assessed in a prospective, standardized manner. The investigators used a neurologic outcome measure (the mRS) that allows one to compare these results with other cohorts. Although the present study includes a relatively large number of children, when subdivided into several age groups numbers were still somewhat modest. This fact reduces the number of variables that could be studied. For example, size of the lesion as well as intrahemispheric location may have been important factors in outcome but were not evaluated. Etiology was also not assessed and potentially could provide important information. One of the main limitations of the study is the fact that in the youngest age group
outcome was often assessed using a developmental scale that may not be predictive of future intellectual function. The study also did not include neonatal stroke patients, an important group since they account for up to 30% of pediatric arterial ischemic strokes. Despite the limitations, the study provides important information that will be useful for practitioners. Sex and side of the lesion do not appear to affect outcome. Thus, parents of a child with a large left hemisphere lesion do not need to expect a prominent aphasia. There is a negative effect of seizures on cognitive outcome. Previous studies4 have also demonstrated the negative effect of seizures in children after perinatal stroke and highlight the importance of seizures in influencing outcome at any age from birth through childhood. Early age at onset of stroke may be a risk factor for negative outcome, and those children should be enrolled in rehabilitative therapy proactively to reduce as much as possible the negative consequences of brain damage. Children who have more neurologic impairment and limitations of motor and sensory functions are at higher risk for poorer cognitive outcome. These clinical features will help the clinician target children who might benefit most from neuropsychological screening and intervention. This information can provide guidance for the clinician’s approach to childhood stroke. AUTHOR CONTRIBUTIONS Doris A. Trauner: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. Warren Lo: drafting/revising the manuscript.
STUDY FUNDING No targeted funding reported.
DISCLOSURE The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
REFERENCES 1. Studer M, Boltshauser E, Capone Mori A, et al. Factors affecting cognitive outcome in early pediatric stroke. Neurology 2014;82:784–792.
See page 784 From the Departments of Neurosciences and Pediatrics (D.A.T.), University of California, San Diego, La Jolla; Rady Children’s Hospital (D.A.T.), San Diego, CA; The Ohio State University College of Medicine (W.L.), Columbus; and Nationwide Children’s Hospital (W.L.), Columbus, OH. 742
© 2014 American Academy of Neurology
2.
3.
Westmacott R, Askalan R, MacGregor D, Anderson P, DeVeber G. Cognitive outcome following unilateral arterial ischaemic stroke in childhood: effects of age at stroke and lesion location. Dev Med Child Neurol 2010;52:386–393. Max JE, Bruce M, Keatley E, Delis D. Pediatric stroke: plasticity, vulnerability and age of lesion onset. J Neuropsychiatry Clin Neurosci 2010;22:30–39.
4.
5.
Ballantyne AO, Spilkin AM, Hesselink J, Trauner DA. Plasticity in the developing brain: Intellectual, language and academic functions in children with ischaemic perinatal stroke. Brain 2008;131:2975–2985. Kitchen L, Westmacott R, Friefeld S, et al. The pediatric stroke outcome measure: a validation and reliability study. Stroke 2012;43:1602–1608.
Neurology 82
March 4, 2014
743
Big strokes for little folks Doris A. Trauner and Warren Lo Neurology 2014;82;742-743 Published Online before print January 31, 2014 DOI 10.1212/WNL.0000000000000174 This information is current as of January 31, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/82/9/742.full.html
References
This article cites 5 articles, 3 of which you can access for free at: http://www.neurology.org/content/82/9/742.full.html##ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): All Cerebrovascular disease/Stroke http://www.neurology.org//cgi/collection/all_cerebrovascular_disease_ stroke Pediatric stroke; see Cerebrovascular Disease/ Childhood stroke http://www.neurology.org//cgi/collection/pediatric_stroke_see_cerebro vascular_disease-childhood_stroke
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
Big strokes for little folks
Doris A. Trauner, MD Warren Lo, MD
Correspondence to Dr. Trauner: [email protected] Neurology® 2014;82:742–743
Pediatric stroke occurs with an incidence of 2–13/ 100,000 and may account for major neurologic impairment in stroke survivors. Outcomes vary and numerous factors may account for that variability. Such factors include age at stroke occurrence, location and size of the affected brain regions, presence or absence of seizures, and etiology. Because of these variables, practitioners have limited data upon which to provide families with accurate prognostic information. In this issue of Neurology®, Studer et al.1 used a population-based approach to identify factors influencing outcome after pediatric stroke. Using the Swiss Neuropediatrics Stroke Registry, they identified all children diagnosed with stroke between 1 month and 16 years of age since 2000. Ninety-nine children were available for study and received neurologic and psychological testing. The authors found that younger age at onset, presence of seizures, lesion location that included both cortical and subcortical regions, and severe neurologic impairment were risk factors for poor cognitive outcome. This study confirms and extends earlier work that found similar results in pediatric stroke patients.2–4 Of note, 40% had no functional deficit and 70% had modified Rankin Scale (mRS) scores #2, which suggests that a substantial number of children had good outcomes, similar to another study that reported long-term neurologic outcome.5 This study is important in that it is one of the largest cohorts reported to date for which the patients were assessed in a prospective, standardized manner. The investigators used a neurologic outcome measure (the mRS) that allows one to compare these results with other cohorts. Although the present study includes a relatively large number of children, when subdivided into several age groups numbers were still somewhat modest. This fact reduces the number of variables that could be studied. For example, size of the lesion as well as intrahemispheric location may have been important factors in outcome but were not evaluated. Etiology was also not assessed and potentially could provide important information. One of the main limitations of the study is the fact that in the youngest age group
outcome was often assessed using a developmental scale that may not be predictive of future intellectual function. The study also did not include neonatal stroke patients, an important group since they account for up to 30% of pediatric arterial ischemic strokes. Despite the limitations, the study provides important information that will be useful for practitioners. Sex and side of the lesion do not appear to affect outcome. Thus, parents of a child with a large left hemisphere lesion do not need to expect a prominent aphasia. There is a negative effect of seizures on cognitive outcome. Previous studies4 have also demonstrated the negative effect of seizures in children after perinatal stroke and highlight the importance of seizures in influencing outcome at any age from birth through childhood. Early age at onset of stroke may be a risk factor for negative outcome, and those children should be enrolled in rehabilitative therapy proactively to reduce as much as possible the negative consequences of brain damage. Children who have more neurologic impairment and limitations of motor and sensory functions are at higher risk for poorer cognitive outcome. These clinical features will help the clinician target children who might benefit most from neuropsychological screening and intervention. This information can provide guidance for the clinician’s approach to childhood stroke. AUTHOR CONTRIBUTIONS Doris A. Trauner: drafting/revising the manuscript, study concept or design, analysis or interpretation of data. Warren Lo: drafting/revising the manuscript.
STUDY FUNDING No targeted funding reported.
DISCLOSURE The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
REFERENCES 1. Studer M, Boltshauser E, Capone Mori A, et al. Factors affecting cognitive outcome in early pediatric stroke. Neurology 2014;82:784–792.
See page 784 From the Departments of Neurosciences and Pediatrics (D.A.T.), University of California, San Diego, La Jolla; Rady Children’s Hospital (D.A.T.), San Diego, CA; The Ohio State University College of Medicine (W.L.), Columbus; and Nationwide Children’s Hospital (W.L.), Columbus, OH. 742
© 2014 American Academy of Neurology
2.
3.
Westmacott R, Askalan R, MacGregor D, Anderson P, DeVeber G. Cognitive outcome following unilateral arterial ischaemic stroke in childhood: effects of age at stroke and lesion location. Dev Med Child Neurol 2010;52:386–393. Max JE, Bruce M, Keatley E, Delis D. Pediatric stroke: plasticity, vulnerability and age of lesion onset. J Neuropsychiatry Clin Neurosci 2010;22:30–39.
4.
5.
Ballantyne AO, Spilkin AM, Hesselink J, Trauner DA. Plasticity in the developing brain: Intellectual, language and academic functions in children with ischaemic perinatal stroke. Brain 2008;131:2975–2985. Kitchen L, Westmacott R, Friefeld S, et al. The pediatric stroke outcome measure: a validation and reliability study. Stroke 2012;43:1602–1608.
Neurology 82
March 4, 2014
743
Big strokes for little folks Doris A. Trauner and Warren Lo Neurology 2014;82;742-743 Published Online before print January 31, 2014 DOI 10.1212/WNL.0000000000000174 This information is current as of January 31, 2014 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/82/9/742.full.html
References
This article cites 5 articles, 3 of which you can access for free at: http://www.neurology.org/content/82/9/742.full.html##ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): All Cerebrovascular disease/Stroke http://www.neurology.org//cgi/collection/all_cerebrovascular_disease_ stroke Pediatric stroke; see Cerebrovascular Disease/ Childhood stroke http://www.neurology.org//cgi/collection/pediatric_stroke_see_cerebro vascular_disease-childhood_stroke
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
