CC BY
20UDC: 616.1
ETIOLOGICAL AND CLINICAL ASPECTS OF
PEDIATRIC STROKE
Kadyrova A. Sh., Atykanov A. O. International Higher School of Medicine, Bishkek, the Kyrgyz Republic
Abstract
The paper presents data from a survey of21 children with a verified diagnosis of stroke, of which 14 children with ischaemic stroke and 7 children with bloodstroke. The survey was conducted in the interim 2014 - 2020 in the City clinical emergency hospital for children in Bishkek and in clinic Cortex. The average age of children was 5.3 ± 2.2 years. In 47.5.4% of stroke cases, the causes were not identified. The clinical symptoms were dominated by convulsions (52%) and hemiplegia (34%).
Key words: children, stroke, ischaemic stroke, bloodstroke.
БАЛДАР ИНСУЛЬТУНУН ЭТИОЛОГИЯЛЫК ЖАНА КЛИНИКАЛЫК АСПЕКТИЛЕРИ
Кадырова А.Ш., Атыканов А.О. Эл аралык Жогорку Медициналык Мектеби, Бишкек, Кыргыз Республикасы
Аннотация
Бул иште такталган инсульт диагнозу бар 21 баланын изилдeeлeрYHYн маалыматтары келтирилген, анын ичинен ишемиялык инсульт менен ооруган 14 бала жана геморрагиялык инсульт менен ооруган 7 бала. Изилдеелер 2014-2020-жылдар аралыгында Бишкек шаардык балдар тез медициналык жардам клиникалык ооруканасында жана «Кортекс» клиникасында жYргYЗYлгвн. Балдардын орточо жашы 5,3±2,2 жашты тYздY. Инсульт болгондордун 47,5,4%ында себептери аныкталган эмес. Клиникалык симптомдордо титиреп-калтыроо (52%) жана гемиплегия (34%) басымдуулук кылган.
Ачкыч свздвр: балдар, инсульт, ишемиялык инсульт, геморрагиялык инсульт.
Correspondent author - Atykanov Arystanbek Orozalievich +996 558 056 501
ЭТИОЛОГИЧЕСКИЕ И КЛИНИЧЕСКИЕ АСПЕКТЫ
ДЕТСКОГО ИНСУЛЬТА
Кадырова А.Ш., Атыканов А.О. Международная высшая школа медицины, г. Бишкек, Кыргызская Республика Аннотация
В работе представлены данные обследования 21 детей с верифицированным диагнозом - инсульт, из которых, 14 детей - с ишемическим инсультом и 7 детей - с геморрагическим инсультом. Обследование проведено в период 2014 - 2020 гг. в Городской детской клинической больнице скорой медицинской помощи г. Бишкек и клинике «Кортекс». Средний возраст детей составил 5,3 ± 2,2 года. В 47,5.4% случаев инсульта причины не были установлены. В клинической симптоматике преобладали судороги (52%) и гемиплегия (34%).
Ключевые слова: дети, инсульт, ишемический инсульт, геморрагический инсульт.
Introduction
Pediatric stroke remains an understudied pathology. Most population-based studies of pediatric stroke were conducted in Europe or North America. The frequency of pediatric stroke is estimated at 2.5 - 2.7 cases per 100,000 children per year in North America and 13 cases per year in France. In England, the incidence of arterial ischaemic stroke (AIS) in children under 1 year of age is the highest: 4.14 per 100,000 children [6]. For Canada, data on AIS in newborns was 10.2 per 100,000 newborns, and in children - 1.72 [8]. According to the E-Health Center of the Kyrgyz Republic, reporting the overall incidence of children over the past 10 years, in children aged 1 month to 15 years, stroke was not registered from 2010 to 2014. From 2015 to 2019, this diagnosis occurred in only 0.1 per 100,000 populations. Since 2020, the incidence of childhood stroke increased to 0.2.
Stroke is one of the top ten causes of death among children in the United States,
with the highest incidence in the first year of life, with an average of 244 deaths per year. Interethnic factors play an important role in pediatric stroke. Thus, children of the Negroid race are more likely to suffer from sickle-cell anemia, and as a result, a stroke. Stroke in childhood has two types: 1 - occurs in the period from the 28th week of gestation to the 30th day of life (perinatal); 2 - from 1 month of life to 18 years [1-3]. The problem of ischaemic stroke (IS) in children seems to be relevant due to the high level of disability and mortality. According to generalized data, 10-15% of patients die during the acute period of IS and about 60-70% of patients who had cerebral infarction have a persistent neurological deficit and need external assistance [2]. About 40-45% of all cases of stroke occur before the age of 5 years, which negatively affects the further mental and physical development of patients [4]. The average risk of developing recurrent IS is 25%, which determines the rational of secondary prevention of stroke.
Despite the presence of established causes of stroke in children, there are difficulties in identifying the factor responsible for the development of the disease at a particular time in a particular patient. In 15-20% of cases, the etiology of stroke remains unidentified. The clinical picture is also ambiguous, ranging from vague to evident symptoms of the disease [5].
All this determined the need for the present study.
Objective: to determine the risk factors and clinical spectrum of stroke in children in the Kyrgyz Republic.
Materials and methods
The object of the study were 21 children with a coded stroke discharge report, who were treated at the City clinical emergency hospital for children in Bishkek and the clinic Cortex in the interim 2014 to 2020. The average age of children at admission was 5.3 ± 2.2 years. IS was diagnosed in 66% (14 children), hemorrhagic stroke (HS) - in 33% (7 children). The diagnosis of stroke in children was verified on the basis of clinical evidence and magnetic resonance tomography (MRT) data of brain using a Philips Achieva scanner (Netherlands) with a magnetic field intensity
of 3 and 1.5 Tesla using 32 or 16-channel head coils.The MRT protocol included the following pulse sequences: 3D T1, T2, FLAIR 3D, SWI and DWI with ADC mapping. T1-weighted turbo-echo images (TFE)with parallel data acquisition technique (SENSE), time repetition (TR) 6.7 ms, time of echo (TE) 3.0 ms. Voxel size -1x1 mm, slice thickness - 1.0 mm in sagittal projection with reconstruction in three planes. Magnetic susceptibility weighted imaging - with parallel acquisition technique, time repetition - 31 ms, time of echo - 0 ms, voxel size - 0.6 x 0.9 mm, slice thickness - 2.5 mm in axial projection. Statistical data are presented in absolute and percentage values.
Results and discussion
As can be seen from the data in Figure 1, in most cases, the causes of stroke remained unknown - 10 children (47.54%). 3 patients (14.2%) were diagnosed with the late hemorrhagic disease of the newborn; 5 children (23.8%) had infection of the upper respiratory tract; 2 children (9.5%) had syno-venous thrombosis; 1 child (4.76%) had mitochondrial encephalopathy with lactic acidosis; 1 child (4.76%) had a family history of stroke.
1 - idiopathic cases;
2 - late hemorrhagic disease of the newborn;
3 - infections of the upper respiratory tract;
4 - synovenous thrombosis;
5 - mitochondrial encephalopathy;
6 - family history of stroke.
Figure 1. Risk factors for stroke in children
The predominant symptoms of stroke in the examined children were (Figure 2) convulsions (52%) and hemiplegia (34%). Other clinical manifestations of the disease included: decreased consciousness (30%), headaches (22%), visual field defects (12%), dysphasia (10%) and lethargy (8%).
Localization of IS in 7 cases was characterized by infarction involving the territory of the middle cerebral artery on the right, which were limited to subcortical structures such as the basal ganglia or the internal capsule, or a combination of both. Involvement of the posterior cerebral artery occurred in 3 cases, and with involvement of
the districts of the cerebellar/basilar artery in 2 cases. Two children developed secondary hemorrhagic transformation after the initial thrombotic event. In children with HI, subarachnoidal hemorrhage was diagnosed in 2 cases. In 4 children, intra-cerebral hemorrhage in one focus and in lchild - in multiple foci were diagnosed.
Relapse of the disease occurred in 5 cases. Long-term neurological deficits occurred in 9 patients, which included mental retardation, epilepsy, and hemiplegia. At the same time, the functional deficit was classified as severe in 7 cases, and as mild in 2 cases.
60
50
40
30
20
10
0
1
2
3
4
5
6
7
1 - convulsions;
2 - hemiplegia;
3 - decrease in consciousness;
4 - headaches;
5 - visual field defects;
6 - dysphasia;
7 - lethargy.
Figure 2. Clinical manifestations of stroke in children.
Among the examined children, the only significant risk factor for long-term neurological deficit was determined to be convulsions in the initial stage. Other factors and clinical features were not relevant for long-term deficiency
Consequently, IS is more likely to manifest with focal neurological symptoms, while HI is characterized by cerebral symptoms, primarily in the form of impaired consciousness. There is an assumption that hemorrhagic transformation of IS is more specifically attributed to small vessel lesions and may be an evidence of present microvascular pathology with a high risk of recurrent stroke [7,9].
Conclusions:
• In most cases (47,54) the causative risk factors for stroke in children remain unknown, with seizures (52%) and hemiplegia (30%) b e i n g t h e m a i n c l i n i c a l manifestations.
K.R.Braun, M.F.Rafay, C.S.Uiterwaal [ et.al. ] // Stroka.-2007; 38:298-302.
5.Lanthier, S. Stroke in children: the coexistence of multiple risk factirs predicts poor outcome /
5.Lanthier, L.Carmant, M.David [ et.al. ] // Neurology.-2000; 54:371-378.
6.Mallick, A.A. Childhood arterial ischaenic stroke incidence, presenting features, and risk factors: a prospective population - based study / A.A.Mallick, V.Ganesan, F.J.Kirkham [ et.al. ] //Lancet Neurol. 2014. Jan; 13(1) : 35-43: 2013 doi: 10.1016 / S 1474-4422 (13) 70290-4. EpubDec.2. 7.Ovbiiagete, B. Predictors of cerebral microbleeds in acute ischemic stroke and TIA patients / B.Ovbiagete, J.L.Saver, N.Sanossian [ et.al. ] // CerebrovascDis.-2006; 22 (5-6): 378-383.
8.de Veber G.A. Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry / G.A.de Veber, A.Kirton, F.A.Rooth [ et.al. ] // PediatrNeurol.-2017. Apr.- 69:59.- doi: 10.1016/ J. Pediatr neurol. 2017. 01.70016.Epub 2017 Jan. 26.
9.Werring, D.J. Cerebral microblelds are common in ischemic stroke but rare in TIA / D.J.Werring, L.J.Coward, N.A.Losseff // Neurology.- 2005; 65 (12): 1914-1918.
Conflict of interest: the authors did not have a conflict of interest when writing the article.
Reference:
1. Zykov, V.P. Population-based studies of cerebral stroke in children in Moscow/Zykov V.P., Cherkasov V.G., Stepahishev I.L. [et all] //Almanac of clinical medicine.-2005.-V.8-№3.-P. 5-9.
2. Zykov, V.P. Diagnosis and treatment of stroke in children / Zykov V.P., Shiretorova D.Ch., Chuchin M.Yu. [etall]//Textbook.-M.: Sovery Press, 2006.-P.64.
3.Zykov, V.P. Diagnosis of ischemic stroke in children (literature review, analysis of a clinical case) / Zykov V.P., Komarova I.B., Chuchin M.Yu. [et all] // Journal of Neurology and Psychiatry. By KorsakovS.S.. - 2008; 22.
4.Braun, K.R. Mode of onset predicts etiological diagnosis of arterial ischemic stroke in children /
