Stroke in Saudi children. Epidemiology, clinical features and risk factors

To describe the epidemiology and clinical features of stroke in a prospective and retrospective cohort of Saudi children and ascertain the causes, pathogenesis, and risk factors.The Retrospective Study Group [RSG] included children with stroke who were evaluated at the Division of Pediatric Neurology, or admitted to King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia during the period July 1992 to February 2001. The Prospective Study Group [PSG] included those seen between February 2001 and March 2003. During the combined study periods of 10 years and 7 months, 117 children [61 males and 56 females, aged one month-12 years] were evaluated; the majority [89%] of these were Saudis. The calculated annual hospital frequency rate of stroke was 27.1/100,000 of the pediatric [1 month - 12 years] population. The mean age at onset of the initial stroke in the 104 Saudi children was 27.1 months [SD = 39.3 months] and median was 6 months. Ischemic strokes accounted for the majority of cases [76%]. Large-vessel infarcts [LVI, 51.9%] were more common than small-vessel lacunar lesions [SVLL, 19.2%]. Five patients [4.8%] had combined LVI and SVLL. Intracranial hemorrhage was less common [18.2%], whereas sinovenous thrombosis was diagnosed in 6 [5.8%] patients. A major risk factor was identified in 94 of 104 [89.4%] Saudi children. Significantly more hematologic disorders and coagulopathies were identified in the PSG compared to the RSG [p=0.001], reflecting a better yield following introduction of more comprehensive hematologic and coagulation laboratory tests during the prospective study period. Hematologic disorders were the most common risk factor [46.2%], presumed perinatal ischemic cerebral injury was a risk factor in 23 children [22.1%] and infectious and inflammatory disorders of the circulatory system in 18 [17.3%]. Congenital and genetic cerebrovascular anomalies were the underlying cause in 7 patients [6.7%] and cardiac diseases in 6 [5.8%]. Six patients [5.8%] had moyamoya syndrome, which was associated with another disease in all of them. Inherited metabolic disorders [3.8%] included 3 children with Leigh syndrome and a 29-month-old girl with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes. Systemic vascular disease was a risk factor in 3 children [2.9%] including 2 who had hypernatremic dehydration; and post-traumatic arterial dissection was causative in 3 cases [2.9%]. Several patients had multiple risk factors, whereas no risk factor could be identified in 11 [10.6%]. Due to the high prevalence and importance of multiple risk factors, a comprehensive investigation, including hematologic, neuroimaging and metabolic studies should be considered in every child with stroke

Perinatal stroke in Saudi children. Clinical features and risk factors

To describe the clinical features and presentations of perinatal stroke in a prospective and retrospective cohort of Saudi children and ascertain the risk factors. Patients with perinatal stroke were identified from within a cohort of 104 Saudi children who were evaluated at the Division of Pediatric Neurology at King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia from July 1992 to February 2001 [retrospective study] and February 2001 to March 2003 [prospective study]. Neuroimaging for suspected cases of stroke consisted of cranial CT, MRI, or both. During the study period, 23 [22%] of 104 children [aged one month to 12 years] were diagnosed to have had perinatal stroke. The male:female ratio was 1.6:1. Ten [67%] of the 15 children who had unilateral ischemic involvement had their lesion in the left hemisphere. The presentation of the ischemic result was within 24-72 hours of life in 13 [57%] patients, and in 6 children [26%], motor impairment was recognized at or after the age of 4 months. Nine children [39%] had seizures at presentation. Pregnancy, labour, and delivery risk factors were ascertained in 18 [78%] cases. The most common of these included emergency cesarean section in 5 cases, and instrumental delivery in another 5. Screening for prothrombotic risk factors detected abnormalities in 6 [26%] patients on at least one test carried out between 2 months and 9 years of age. Four children [17%] had low protein C, which was associated with low protein S and raised anticardiolipin antibodies [ACA] in one patient, and low antithrombin III in another. Low protein S was detected in a 42-month-old boy. The abnormality in the sixth child was confined to raised ACA. The present study highlights the non-specific features by which stroke presents during the neonatal period. The data are in keeping with the potential role for inherited and acquired thrombophilia as being the underlying cause. However, the high prevalence of additional acquired antenatal and perinatal risk factors support a multifactorial disorder

Outcome of stroke in Saudi children

To report on the prognosis, neurologic outcome, and recurrences of stroke in Saudi children. We evaluated a cohort of 104 Saudi children with stroke at the Division of Pediatric Neurology at King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia from July 1992 to February 2001 [retrospective study] and February 2001 to March 2003 [prospective study]. We analyzed the salient clinical, neuroimaging, neurophysiological, neuropsychological and laboratory data following retrieval from a specialty designed comprehensive protocol. Of the 104 children in the cohort [aged one month to 12 years], 5 [4.8%] died during the study period and 9 [8.7%] were lost to follow-up. The mean duration of follow-up for the remaining 90 children was 40 months [median 33 months]. Recovery was judged complete in 6 [6.7%] of these 90 children. We detected residual hemiparesis [irrespective of its effect on daily functions] in 73 [81%] and this was combined with other motor deficits in 45 children [50%]. Forty-one children [46%] had residual dysphasia or language deficits, whereas 45 [50%] were judged to have had cognitive deficit. Psychometry revealed an abnormal intelligence quotient test [<70] in 19 of 26 [73%] children. Other neurologic sequelae included epilepsy in 52 [58%], recurrent headaches in 13 [14%] and hydrocephalus in 4 [4.4%] patients. Six of the 95 [6.3%] children, who were ascertained to have died or kept their follow-up, had one or more recurrences, one month to 5 years after the initial stroke [median 23 months]. Patients who had recurrent strokes were significantly more likely to be the product of consanguineous marriages [P=0.04]. Regarding the group of 23 children with perinatal stroke, neither deaths nor recurrences occurred during the follow-up period. However, 20 [87%] of them had significant delays in their developmental milestones. The toll of stroke in Saudi children is demanding, with most children demonstrating persistent neurologic or cognitive deficits. Primary prevention for recurrences is feasible through informed genetic counseling