title: Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry.
abstract: Pediatric arterial ischemic stroke remains incompletely understood. Population-based epidemiological data inform clinical trial design but are scant in this condition. We aimed to determine age-specific epidemiological characteristics of arterial ischemic stroke in neonates (birth to 28 days) and older children (29 days to 18 years).
  
  
  
  We conducted a 16-year, prospective, national population-based study, the Canadian Pediatric Ischemic Stroke Registry, across all 16 Canadian acute care children's hospitals. We prospectively enrolled children with arterial ischemic stroke from January 1992 to December 2001 and documented disease incidence, presentations, risk factors, and treatments. Study outcomes were assessed throughout 2008, including abnormal clinical outcomes (stroke-related death or neurological deficit) and recurrent arterial ischemic stroke or transient ischemic attack.
  
  
  
  Among 1129 children enrolled with arterial ischemic stroke, stroke incidence was 1.72/100,000/year, (neonates 10.2/100,000 live births). Detailed clinical and radiological information were available for 933 children (232 neonates and 701 older children, 55% male). The predominant clinical presentations were seizures in neonates (88%), focal deficits in older children (77%), and diffuse neurological signs (54%) in both. Among neonates, 44% had no discernible risk factors. In older children, arteriopathy (49% of patients with vascular imaging), cardiac disorders (28%), and prothrombotic disorders (35% of patients tested) predominated. Antithrombotic treatment increased during the study period (P < 0.001). Stroke-specific mortality was 5%. Outcomes included neurological deficits in 60% of neonates and 70% of older children. Among neonates, deficits emerged during follow-up in 39%. Overall, an initially decreased level of consciousness, a nonspecific systemic presentation, and the presence of stroke risk factors predicted abnormal outcomes. For neonates, predictors were decreased level of consciousness, nonspecific systemic presentation, and basal ganglia infarcts. For older children, predictors were initial seizures, nonspecific systemic presentation, risk factors, and lack of antithrombotic treatment. Recurrent arterial ischemic stroke or transient ischemic attack developed in 12% of older children and was predicted by arteriopathy, presentation without seizures, and lack of antithrombotic treatment. Emerging deficit was predicted by neonatal age at stroke and by cardiac disease.
  
  
  
  This national data set provides a population-based disease incidence rate and demonstrates the protective effect of antithrombotic treatment in older children, and frequent long-term emerging deficits in neonates and in children with cardiac disorders. Further clinical trials are required to develop effective age-appropriate treatments for children with acute arterial ischemic stroke.
authors.affiliation: Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada. Electronic address: gabrielle.deveber@sickkids.ca.
authors.forename: Gabrielle A
authors.initials: GA
authors.lastname: deVeber
authors.affiliation: Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Kirton
authors.affiliation: Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Frances A
authors.initials: FA
authors.lastname: Booth
authors.affiliation: Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Jerome Y
authors.initials: JY
authors.lastname: Yager
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Elaine C
authors.initials: EC
authors.lastname: Wirrell
authors.affiliation: Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Ellen
authors.initials: E
authors.lastname: Wood
authors.affiliation: Department of Pediatrics, McGill University, Montreal, Quebec, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Shevell
authors.affiliation: Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Ann-Marie
authors.initials: AM
authors.lastname: Surmava
authors.affiliation: Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Patricia
authors.initials: P
authors.lastname: McCusker
authors.affiliation: Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: M Patricia
authors.initials: MP
authors.lastname: Massicotte
authors.affiliation: Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Daune
authors.initials: D
authors.lastname: MacGregor
authors.affiliation: Department of Pediatrics, Queen's University, Kingston, Ontario, Canada.
authors.forename: E Athen
authors.initials: EA
authors.lastname: MacDonald
authors.affiliation: Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Brandon
authors.initials: B
authors.lastname: Meaney
authors.affiliation: Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Levin
authors.affiliation: Department of Pediatrics, University of Sherbrooke, Sherbrooke, Quebec, Canada.
authors.forename: Bernard G
authors.initials: BG
authors.lastname: Lemieux
authors.affiliation: Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Jardine
authors.affiliation: Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Humphreys
authors.affiliation: Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.
authors.forename: Michèle
authors.initials: M
authors.lastname: David
authors.affiliation: Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Anthony K C
authors.initials: AK
authors.lastname: Chan
authors.affiliation: Department of Pediatrics, Janeway Children's Health and Rehabilitation Centre, St. John's, Newfoundland, Canada.
authors.forename: David J
authors.initials: DJ
authors.lastname: Buckley
authors.affiliation: Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Bjornson
mesh_terms: D000293:Adolescent; D002545:Brain Ischemia / Q000453:epidemiology* / Q000628:therapy*; D002170:Canada / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000628:therapy*; D016896:Treatment Outcome
keywords: epidemiology; incidence; ischemic; pediatric; stroke