Association Between Prolonged Seizures and Malignant Middle Cerebral Artery Infarction in Children With Acute Ischemic Stroke.
Malignant middle cerebral artery infarct syndrome is a potentially fatal complication of stroke that is poorly understood in children. We studied the frequency, associated characteristics, and outcomes of this condition in children.



Children, aged two months to 18 years with acute middle cerebral artery infarct diagnosed at our center between January 2005 and December 2012 were studied. Associations with malignant middle cerebral artery infarct syndrome were sought, including age, seizures, neurological deficit severity (Pediatric National Institute of Health Stroke Severity Score), stroke etiology, fever, blood pressure, blood glucose, infarct location, infarct volume (modified pediatric Alberta Stroke Program Early Computed Tomography Score), and arterial occlusion. Death and neurological outcomes were determined.



Among 66 children with middle cerebral artery stroke, 12 (18%) developed malignant middle cerebral artery infarct syndrome, fatal in three. Prolonged seizures during the first 24 hours (odds ratio, 25.51; 95% confidence interval, 3.10 to 334.81; P = 0.005) and a higher Pediatric National Institute of Health Stroke Severity Score (odds ratio, 1.22; 95% confidence interval, 1.08 to 1.45; P = 0.006) were independently associated with malignant middle cerebral artery infarct syndrome. All children aged greater than two years with a Pediatric National Institute of Health Stroke Severity Score ≥8 and initial seizures ≥5 minutes duration developed malignant middle cerebral artery infarct syndrome (100%).



Malignant middle cerebral artery infarct syndrome affects nearly one in five children with acute middle cerebral artery stroke. Children with higher Pediatric National Institute of Health Stroke Severity Scores and prolonged initial seizures are at greatly increased risk for malignant middle cerebral artery infarct syndrome. Children with middle cerebral artery infarcts warrant intensive neuroprotective management and close monitoring to enable early referral for hemicraniectomy surgery.
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Electronic address: Andrea.Andrade@lhsc.on.ca.
Andrea
A
Andrade
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Sandra
S
Bigi
Division of Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Division of Neuroradiology, Department of Medical Imaging, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Suzanne
S
Laughlin
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Sujatha
S
Parthasarathy
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Adriane
A
Sinclair
Division of Neurosurgery, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Peter
P
Dirks
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Ann Marie
AM
Pontigon
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Mahendranath
M
Moharir
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Rand
R
Askalan
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Daune
D
MacGregor
Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Gabrielle
G
deVeber
D000293:Adolescent; D000367:Age Factors; D001921:Brain / Q000000981:diagnostic imaging; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D020244:Infarction, Middle Cerebral Artery / Q000150:complications* / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology; D008297:Male; D012189:Retrospective Studies; D012640:Seizures / Q000150:complications* / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology; D012720:Severity of Illness Index; D013997:Time Factors
children; hemicraniectomy; infarction; middle cerebral artery; seizures