title: Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study.
abstract: OBJECTIVE
  Published cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20%. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era.
  
  
  METHODS
  The Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review.
  
  
  RESULTS
  Of the 355 children, 354 survived their acute index stroke, and 308 (87%) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8% (95% confidence interval, 4.6%-10%) at 1 month and 12% (8.5%-15%) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95% confidence interval, 1.8-14). The 1-year recurrence rate was 32% (95% confidence interval, 18%-51%) for moyamoya, 25% (12%-48%) for transient cerebral arteriopathy, and 19% (8.5%-40%) for arterial dissection.
  
  
  CONCLUSIONS
  Children with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed.
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.). heather.fullerton@ucsf.edu.
authors.forename: Heather J
authors.initials: HJ
authors.lastname: Fullerton
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Max
authors.initials: M
authors.lastname: Wintermark
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Hills
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Michael M
authors.initials: MM
authors.lastname: Dowling
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Marilyn
authors.initials: M
authors.lastname: Tan
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Mubeen F
authors.initials: MF
authors.lastname: Rafay
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Mitchell S V
authors.initials: MS
authors.lastname: Elkind
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: A James
authors.initials: AJ
authors.lastname: Barkovich
authors.affiliation: From the Departments of Neurology (H.J.F., N.K.H., A.J.B.), Pediatrics (H.J.F.), Biostatistics and Epidemiology (N.K.H.), and Radiology (A.J.B), University of California, San Francisco; Department of Radiology, Stanford University, Palo Alto, CA (M.W.); Departments of Pediatrics and Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX (M.M.D.); Departments of Pediatrics and Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines (M.T.); Section of Neurology, Children's Hospital, University of Manitoba, Winnipeg, Manitoba, Canada (M.F.R.); Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (M.S.V.E.); Department of Epidemiology, Mailman School of Public Health, New York, NY (M.S.V.E.); and Department of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada (G.A.d.V.).
authors.forename: Gabrielle A
authors.initials: GA
authors.lastname: deVeber
mesh_terms: D000293:Adolescent; D002545:Brain Ischemia / Q000175:diagnosis* / Q000453:epidemiology*; D002539:Cerebral Arterial Diseases / Q000175:diagnosis / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D038622:Internationality; D008297:Male; D011446:Prospective Studies; D012008:Recurrence; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology*
keywords: child; pediatrics; risk factor; stroke; vaccination