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ENDOVASCULAR TREATMENT WITH AND WITHOUT INTRAVENOUS THROMBOLYSIS IN LARGE VESSEL OCCLUSIONS STROKE:A SYSTEMATIC REVIEW AND META-ANALYSIS

Session Type
Free Communication Session
Date
28.10.2021, Thursday
Session Time
08:00 - 09:30
Room
FREE COMMUNICATIONS A
Lecture Time
08:50 - 09:00

Abstract

Background and Aims

Previous studies showed conflicting results in the benefits of pretreatment with IVT before endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with large vessel occlusions (LVOs). The aim of this study was to investigate the clinical efficacy and safety of EVT alone versus bridging therapy (BT) in AIS with LVOs.

Methods

A systematic review and meta-analysis of all available studies evaluating clinical outcomes between BT and EVT alone were conducted by electronic searching the NCBI/NLM PubMed and Web of Science database from inception to October 20, 2020. Primary outcomes focus on 90 days good outcome and mortality. Secondary outcomes included successful reperfusion, and sICH. The random-effect model was applied if P<0.10 for Cochran’s Q test or I2>50% for Higgins I2 statistics, otherwise the fixed-effect model was performed.

Results

A total of 93 studies enrolling 45,190 patients were admitted in present analysis. In both unadjusted and adjusted analysis, BT was associated with a higher likelihood of 90 days good outcome (crude odds ratio [cOR] 1.361, 95%CI 1.234-1.502 and adjusted OR[aOR] 1.369, 95%CI 1.217-1.540), successful reperfusion (cOR 1.271, 95%CI 1.149-1.406 and aOR 1.267, 95%CI 1.095-1.465) and lower odds of 90 days mortality (cOR 0.619, 95%CI 0.560-0.684 and aOR 0.718, 95%CI 0.594-0.868) compared with EVT alone. The two groups did not differ in sICH (cOR 1.062, 95%CI 0.915-1.232 and aOR 1.20, 95%CI 0.95-1.47) after evaluating by sensitivity analyses and adjusting for publication bias.

Conclusions

BT benefited more in clinical outcome without increasing the risk of safety compared with EVT alone in AIS patients with LVOs.

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ENDOVASCULAR TREATMENT FOR M3 OCCLUSIONS

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
15:15 - 16:45
Room
FREE COMMUNICATIONS A
Lecture Time
15:15 - 15:25

Abstract

Background and Aims

Endovascular treatment (ET) has become most well-proven beneficial treatment for the M1-2 occlusions of the middle cerebral artery (1-3). Mortality and disability rates are high if large vessel occlusions are not treated (4). Even if these rates are lower in M3 occlusions, the important branch blockages can end with disability. Small vessels occlusions are difficult to detect and treatment for endovascular interventions. There are few studies on the effectiveness of endovascular treatment for M3 occlusions (5,6). In this study, our aim to assess the feasibility, safety, and preliminary efficacy of endovascular therapy for M3 occlusions.

Methods

This study was conducted a retrospective analysis of a prospectively collected database in two- centers for acute ischemic stroke of anterior system between July 2015 and April 2020. Middle cerebral artery is divided into the sections according to the course and angle of the middle cerebral artery. M3 (opercular) segment of the middle cerebral artery is after the circular sulcus of the insula.

Results

The complete or near complete reperfusion (mTICI 2b-3) of m3 occlusion was achieved in 15 cases (38.5%). The complete (mTICI 3) reperfusion was achieved in 24 cases (61.5%). The complete or near complete reperfusion (mTICI 2b-3) of the other anterior circulation occlusion was achieved in 129 cases (65.9%) while the complete (mTICI 3) reperfusion was achieved in 50 cases (27%).

Conclusions

This retrospective study demonstrates the ability of endovascularly treatment of M3 occlusions as effective, reliable and cost-effective.

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HEALTHCARE UTILIZATION IN CRYPTOGENIC STROKE PATIENTS WITH VS. WITHOUT LONG-TERM CARDIAC MONITORING FOR ATRIAL FIBRILLATION: EVIDENCE FROM REAL-WORLD DATA

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
08:00 - 09:30
Room
FREE COMMUNICATIONS A
Lecture Time
08:50 - 09:00

Abstract

Background and Aims

This study estimates differences in healthcare utilization in cryptogenic stroke patients with and without long-term monitoring for atrial fibrillation (AF) with insertable cardiac monitor (ICM), across two U.S. claim databases: Optum® de-identified Clinformatics® database 2007-2019, and Medicare Fee-for-service 5% sample 2010-2019.

Methods

Patients included were ≥18 years and had an incident hospitalization for cryptogenic stroke/TIA, with continuous health plan enrollment 12 months prior to index stroke and ≥15 months follow-up post-stroke. The first 3 months post-stroke was used as a sample identification period to assign cohorts: patients with ICM insertion, and those with ambulatory external cardiac monitoring (ECM) only. Patients with prior AF/Flutter, stroke, cardiomyopathy, valvular diseases, or end-stage renal disease were excluded. Annualized healthcare utilization was estimated using general linear models with multiple data distribution considerations. Covariates included patient characteristics and CHA2DS2-VASc score.

Results

A total of 7,239 patients met inclusion criteria (4,844 Optum® and 2,395 Medicare). Cohorts included 6,051 patients (83.6%) who received ECM only and 1,188 (16.4%) who received ICM. Patient characteristics were similar between cohorts at baseline: age 69±12 years, 54.5% female, average CHA2DS2-VASc=2.7. During follow-up, the ICM cohort experienced a greater number of routine outpatient/office/clinic visits, but fewer acute events, with no difference in average length of stay (see table).

wsc 2021 abstract table.jpg

Conclusions

Analysis of a real-world cryptogenic stroke population showed that continuous cardiac rhythm monitoring with ICM was associated with more frequent care in routine outpatient-based settings. This closer medical management may have contributed to the observed reduction in acute events which carries important implications for patient quality of life.

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IMPACT OF PREVIOUS STROKE ON TWO-YEAR CLINICAL OUTCOMES IN PATIENTS WITH ELDERLY NON-VALVULAR ATRIAL FIBRILLATION: SUB-ANALYSIS OF ANAFIE REGISTRY

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
08:00 - 09:30
Room
FREE COMMUNICATIONS A
Lecture Time
08:40 - 08:50

Abstract

Background and Aims

The All Nippon AF In the Elderly (ANAFIE) Registry is a prospective, multicenter, observational study for elderly non-valvular atrial fibrillation (NVAF) patients aged ≥75 years in Japan. This sub-study aimed to examine two-year outcomes between patients with and without a history of stroke/TIA.

Methods

Total 32,275 patients enrolled for the analysis set of ANAFIE Registry were divided into 2 groups according to a history of stroke/TIA. The incidence rates of outcome events and relevant factors for stroke/systemic embolism (SEE) were analyzed. These were also analyzed by a history of ischemic stroke (IS)/TIA or type of anticoagulant therapy.

Results

The stroke/TIA group (n=7,303) was less female and older (P<0.001 for both) than the no-stroke/TIA group (n=24,972). Compared to no-stroke/TIA group, the stroke/TIA group had higher incidence rate at 2 years for stroke/SEE (HR 2.25, 95% CI 1.97–2.58), major bleeding (HR, 1.25, 95% CI 1.05–1.49), and death (HR, 1.13, 95% CI 1.02–1.24). In the IS/TIA group, patients with direct oral anticoagulants (DOACs, n=4,960) had lower risk of major bleedings (HR 0.70, 95% CI 0.51–0.96) than those with warfarin (n=1,873). The following relevant factors for stroke/SEE were identified in the stroke/TIA group: persistent AF (HR, 1.42, 95% CI 1.06–1.89), long-standing persistent and permanent AF (HR, 1.51, 95% CI 1.19–1.93), and a history of thromboembolism (HR 1.44, 95% CI 1.10–1.87).

Conclusions

Elderly NVAF patients with a history of stroke/TIA had poorer prognosis than those without stroke/TIA. DOACs had a lower bleeding risk than warfarin for those with IS/TIA.

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VAGUS NERVE STIMULATION PAIRED WITH UPPER LIMB REHABILITATION AFTER CHRONIC STROKE: CROSS-OVER RESULTS FROM THE VNS-REHAB PIVOTAL TRIAL.

Session Type
Oral Presentations
Date
27.10.2021, Wednesday
Session Time
12:00 - 13:00
Room
ORAL PRESENTATIONS 1
Lecture Time
12:10 - 12:20

Abstract

Background and Aims

In the VNS-Rehab trial, active Vagus Nerve Stimulation (active-VNS) paired with rehabilitation led to a greater reduction in upper limb impairment compared to sham-VNS paired with rehabilitation. We report here results from participants who received sham-VNS paired with rehabilitation that crossed over to receive active-VNS paired with rehabilitation.

Methods

Forty-nine participants received 6 weeks of in-clinic sham-VNS paired with rehabilitation followed by a 90-day sham-VNS home exercise program. Participants then received 6 weeks of in-clinic active-VNS paired with rehabilitation followed by a 90-day active-VNS home exercise program. Upper limb impairment (Fugl-Meyer Upper Extremity score (FMA-UE)) was assessed at baseline, after the sham-VNS phase, after the 6-weeks of in-clinic active-VNS paired with rehabilitation and after the 90-day active-VNS home exercise program. Values are means[standard error]. Significance difference was set at p<0.05. A clinically meaningful response was defined as a >6 point change in FMA-UE score.

Results

No related or unexpected adverse or serious adverse events were reported. FMA-UE score increased from 35.7[1.1] at baseline by +3.1[0.8] following the sham-VNS phase (p<0.0002). FMA-UE score significantly increased further by +2.8[0.5] (p<0.0001) after 6-weeks of in-clinic active-VNS and by +2.4[0.7] (p<0.002) following the 90 day active-VNS home exercise program. The overall increase from baseline to the end of the active-VNS phase was +5.9[0.9] (p<0.001). A clinically meaningful response occurred in 24% of participants following the sham-VNS phase but increased to 44% following the active-VNS phase.

Conclusions

On average, participants who initially received sham-VNS paired with rehabilitation achieved a further reduction in impairment following active-VNS paired with rehabilitation.

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LONG-TERM REMOTE ISCHEMIC CONDITIONING IN PATIENTS WITH ISCHEMIC STROKE – A RANDOMIZED CONTROLLED CROSS-OVER TRIAL

Session Type
Oral Presentations
Date
27.10.2021, Wednesday
Session Time
08:00 - 08:50
Room
ORAL PRESENTATIONS 1
Lecture Time
08:00 - 08:10

Abstract

Background and Aims

Remote ischemic conditioning (RIC) may have neuroprotective effects. Immediate or long-term RIC may increase cerebral blood flow velocity and cerebrovascular reactivity in patients with ischemic stroke.

Methods

We included patients with cerebral small vessel occlusion stroke in a randomized controlled, open-label, outcome-blinded, cross-over pilot study, with two weeks daily RIC treatment (four cycles of five minutes) and two weeks observation, intersected by three weeks wash-out. At baseline and after each period mean cerebral blood flow velocity in the middle cerebral artery (VMCA) was assessed by transcranial doppler and blood oxygen saturation in the cerebral microvasculature (ScO2) by near infrared spectroscopy (NIRS) at rest, during RIC and finger tapping. Blood pressure (BP) and ankle brachial index (ABI) were recorded. Cognitive function and modified Rankin Score were assessed at baseline.

Results

14 patients, mean age 71±8.1 years, 21% women, NIHSS on admission 3±3.2. Baseline mean values ± SD were; MOCA 26±2.3, VMCA 48.8±8.5 cm/sec, ScO2 68.3±5.7, BP 137/80±18/8 mmHg, ABI 1.08±0.1. VMCA (p=0.50) or ScO2 (p=0.25) did not change during RIC or after each period (p=0.28/p=0.53, VMCA/ScO2 respectively). Finger tapping increased VMCA mean by 4.13% ±6.31 (p=0.029) and ScO2 mean by 0.37% ±0.50 (p=0.02), with no excess change between periods (p=0.9 and 0.96). No change in BP (p=0.68) or ABI (p=0.53).

Conclusions

Cerebrovascular response remained unchanged during RIC and after two weeks daily RIC. RIC did no change peripheral vascular response. More sensitive methods of measuring cerebral blood flow should be applied to evaluate if RIC may improve vascular outcome after ischemic stroke.

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DIETARY PATTERNS AND ODDS OF STROKE – EVIDENCE FROM THE STROKE INVESTIGATIVE RESEARCH AND EDUCATION NETWORK (SIREN) STUDY IN SUB-SAHARAN AFRICA

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
10:00 - 11:30
Room
FREE COMMUNICATIONS A
Lecture Time
10:50 - 11:00

Abstract

Background and Aims

Sub-Saharan Africa (SSA) is gradually becoming the epicentre of stroke worldwide, but continental-wide data alluding to the significance of diets in stroke risk among indigenous Africans are scarce. This study determined the association between dietary patterns (DP) and odds of stroke among Africans.

Methods

3684 strokes patients matched for 3684 controls were recruited across multiple SIREN sites and communities in Nigeria and Ghana. Diet histories (servings and frequency of consumption) were summarized using principal component analysis to identify DP. Stroke was defined using predefined criteria primarily on clinical evaluation following standard operating procedures. Logistic regressions were applied to compute odds ratio (OR) and 95% confidence interval (CI) for stroke risk by tertile distribution of DP at P<0.05.

Results

Mean age was 59.0±13.9years, 45.8% were females, 8.1% and 29.4% reported tobacco and alcohol use respectively. Seven DP (vegetable-dense-diet, poultry&fish-dense-diet, whole grains-diet, fried&sweetened-foods, red-meaty-diet, pickled/processed-foods and fruit-dense-diet) were identified in this sample. Multivariable-adjusted OR (95%CI) for odds of stroke across tertile distribution (lowest tertile as reference) of DP were; 2nd tertile – 0.82 (0.73, 0.92), 3rd – 0.61 (0.54, 0.69) for vegetable-dense-diet, 1.36 (1.22, 1.53), 1.54 (1.37, 1.73) for poultry&fish-dense-diet, 0.77 (0.69, 0.87), 0.81 (0.73, 0.91) for whole-grains-diet, 1.56 (1.39, 1.75), 1.46 (1.30, 1.64) for red-meaty-diet, 1.02 (0.91, 1.14), 1.12 (1.00, 1.26) for pickled/processed-foods, and 0.91 (0.82, 1.02), 0.84 (0.74, 0.94) for fruit-dense diet.

Conclusions

There is a complex association between dietary patterns and odds of stroke, but regular consumption of a vegetable-dense diet was independently associated with reduced odds of stroke.

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UTILIZATION AND OUTCOMES OF ENDOVASCULAR THROMBECTOMY IN PATIENTS 80 YEARS AND OLDER

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
15:15 - 16:45
Room
FREE COMMUNICATIONS A
Lecture Time
15:25 - 15:35

Abstract

Background and Aims

Patients aged 80 and over were often excluded or under-represented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis.

Methods

From a pool of 2.4 million AIS cases in the Get With The Guidelines-Stroke US nationwide registry from April 2012 to June 2019, we identified patients potentially eligible for EVT treatment (i.e., arrived≤6h, NIHSS≥6). We compared EVT use and outcomes between those ages ≥80y vs <80y.

Results

Among 42,422 patients arriving ≤6h and receiving EVT at 614 sites, 12,768 (30.1%) were age ≥80. EVT rates in these potentially EVT-eligible very old patients increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. This increase paralleled that in younger patients so that, by study period end, the relative rate of EVT in ≥80y vs <80y had risen to 0.76. Older patients had poorer outcomes at discharge compared with younger patients, including discharge to home: 12.5% versus 31.1%, aOR 0.43 (95%CI 0.40-0.46), functional independence (mRS 0-2): 10.9% vs 26.6%, aOR 0.45 (0.41-0.49), and inpatient death/hospice, 34.5% vs 16.1%, aOR 2.22 (2.09-2.36). However, symptomatic intracranial hemorrhage rates did not differ, 6.9% vs 6.5%, aOR 1.04 (0.94-1.14).

Conclusions

Use of EVT among the very old has increased dramatically, though rates remain lower than in younger patients. Although favorable functional outcomes at discharge are lower and combined mortality/discharge to hospice higher in the oldest old, the risk of symptomatic intracranial hemorrhage is not increased.

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NON-PHARMACOLOGICAL INTERVENTIONS FOR ALLEVIATING FATIGUE AND PROMOTING SLEEP IN PEOPLE WITH STROKE: A META-ANALYSIS

Session Type
Oral Presentations
Date
27.10.2021, Wednesday
Session Time
12:00 - 12:10
Room
ORAL PRESENTATIONS 3
Lecture Time
12:00 - 12:10

Abstract

Background and Aims

Treating predisposing factors of fatigue such as sleep quality may help reduce fatigue in people with stroke. In the last decade, more interventions have been developed for stroke survivors having fatigue, but the effects of non-pharmacological interventions on fatigue and sleep quality among this population remains unclear. This review aimed to evaluate the effects of non-pharmacological interventions on fatigue and sleep quality among people with stroke.

Methods

We searched the randomized controlled trials about non-pharmacological interventions for alleviating fatigue and promoting sleep in seven databases. The search included the clinical trial registries, reference lists and the forward citations of the included publications. The standardized mean difference (SMD) or mean difference (MD) of fatigue and/or sleep variables at different time points post-intervention were/was estimated using random effects models.

Results

Seventeen studies (n=1,079) were analyzed. Non-pharmacological interventions were summarized into four types: physical intervention, cognitive intervention, oxygen therapy, and traditional Chinese medicine. Compared to the control groups, non-pharmacological interventions significantly improved sleep quality (SMD= -0.76, 95% CI= -1.27 to -0.25) and insomnia (MD= -4.19, 95% CI= -5.77 to -2.60) but not fatigue, sleep apnea, and sleepiness immediately post-intervention. Non-pharmacological interventions had insignificant short and medium-term effects on fatigue, but their longer-term effects on sleep quality, insomnia, and sleepiness were inconclusive.

Conclusions

Non-pharmacological interventions could improve sleep quality and insomnia immediately post-intervention among people with stroke. Further robust studies are needed to determine their immediate and longer-term effects on fatigue and sleep.

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THE DYNAMICS OF SERUM INFLAMMATORY MARKERS IN SUBACUTE STROKE AND ASSOCIATIONS WITH AEROBIC FITNESS TRAINING AND CLINICAL OUTCOME: RESULTS OF THE RANDOMIZED CONTROLLED PHYS-STROKE TRIAL

Session Type
Oral Presentations
Date
27.10.2021, Wednesday
Session Time
10:40 - 11:10
Room
ORAL PRESENTATIONS 2
Lecture Time
10:40 - 10:50

Abstract

Background and Aims

Inflammatory markers are upregulated following stroke. Inflammatory activity after stroke is associated with increased mortality, recurrent vascular risk, and impaired outcome. However, dynamics of inflammatory markers in subacute stroke phases remain unclear. Physical fitness training may play a role in decreasing long-term inflammatory activity after stroke. Aims: To investigate the dynamics of hs-CRP, IL-6, TNF-alpha and fibrinogen in subacute to chronic stroke and to determine whether serum levels are modified by exposure to an early fitness training intervention and associated with functional recovery at follow-up.

Methods

This is an exploratory analysis of patients enrolled in the multicenter randomized-controlled PHYS-STROKE trial. Patients with subacute stroke (day 5-45) and standard rehabilitative therapy were randomized to receive either four weeks of aerobic fitness training or relaxation sessions. GEE-Models were used to investigate the dynamics of inflammatory markers and associations of aerobic fitness training with inflammatory markers over time. Using multiple logistic regression models, we analyzed associations between inflammatory marker levels and functional outcome (measured by mRS or BI) up to six months after stroke.

Results

Hs-CRP, IL-6, and fibrinogen levels declined significantly over time (p all ≤ 0.01). Exposure to aerobic fitness training did not influence levels of inflammatory markers at follow-up. Elevated baseline IL-6 and fibrinogen levels were independently associated with worse functional outcome parameters up until six months.

Conclusions

Elevated serum inflammatory markers gradually decrease after stroke. Increased IL-6 and fibrinogen in early and late subacute stroke phases are associated with impaired functional outcome up to six-months after stroke.

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NEUROIMAGING MARKERS IDENTIFYING NOTCH3-MUTATION RELATED INTRACEREBRAL HEMORRHAGE

Session Type
Free Communication Session
Date
29.10.2021, Friday
Session Time
17:15 - 18:45
Room
FREE COMMUNICATIONS A
Lecture Time
17:15 - 17:25

Abstract

Background and Aims

Hereditary cerebral small vessel disease (CSVD), such as NOTCH3-mutation, is an important differential diagnosis of spontaneous intracerebral hemorrhage (ICH). We aim to identify clinical and imaging characteristics discriminating NOTCH3-mutation related from non-genetic cause of ICH.

Methods

This study was based on a prospectively follow-up CSVD cohort. Next generation sequencing for the common genes of CSVD were performed in patients with ICH and suspicious hereditary cause, such as more severe features of CSVD or younger age of onset. Neuroimaging markers of CSVD, including white matter lesion (WML), lacunes, enlarged perivascular spaces, and cerebral microbleeds (CMB) were compared between patients with and without NOTCH3-mutation.

Results

From 445 patients who had received genetic screening, 47 NOTCH3-mutation and 68 non-genetic patients with ICH were enrolled. Compared with the non-genetic group, patients with NOTCH3-mutation were older, had higher frequency of family history of stroke, thalamus ICH, overwhelming more severe neuroimaging markers of CSVD, especially more CMB in the hippocampus (5.8+/-8.4 vs 0.3+/-0.6) and thalamus (8.4+/-8.2 vs 2.0+/-2.9, both P<0.001). Besides, patients with NOTCH3-mutation and higher risk of recurrent stroke (HR 2.42, 95% CI 1.13–5.20). We further constructed a NOTCH3­-ICH score consisting of history of stroke in the siblings, severe deep WML, higher number of hippocampus CMB (>=2) and thalamus CMB (>=7). The sensitivity and specificity were 0.71 and 0.87 for a cut-off score of 2 points, and the area under the receiver operating characteristics was 0.85 (95% CI 0.77–0.93).

Conclusions

Patients with NOTCH3-mutation related ICH had higher burden of CMB in the hippocampus and thalamus. A NOTCH3-ICH score can be used to identifying potential genetic cause of CSVD.

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A NATIONAL, POPULATION BASED STUDY OF PEDIATRIC HEMORRHAGIC AND ISCHEMIC STROKE

Session Type
Free Communication Session
Date
28.10.2021, Thursday
Session Time
10:00 - 11:30
Room
FREE COMMUNICATIONS A
Lecture Time
10:50 - 11:00

Abstract

Background and Aims

Stroke is an important cause of morbidity and mortality in pediatrics and large studies are needed at both academic and non-academic hospitals to better understand the pathogenesis of pediatric stroke. Large administrative datasets can provide information on risk factors in neonatal and pediatric stroke.

Methods

The data for patients aged 0-18 with a diagnosis of either ischemic or hemorrhagic stroke were extracted from the Cerner Health Facts EMR Database from 2000-2018. Patients were subdivided by age. The prevalence of established risk factors for pediatric stroke was assessed amongst the extracted cases.

Results

10,621 children were identified with stroke. 6,271(59%) were ischemic and 4,350(41%) were hemorrhagic. The percentage of combined stroke by age were 33%(<1 year), 20%(1-4 years), 14%(5-9 years), 11%(10-13 years), and 22%(14-18 years). The most frequently identified risk factors for ischemic stroke were hypertension(36%), trauma(27%), hyperlipidemia(26%) and malignancy(19%). Moyamoya(3%), congenital heart disease(5%), and dissection(1%) were rare in this dataset. The most common risk factors seen with hemorrhagic stroke were trauma(55%), malignancy(11%), arrhythmia(10%) and hypertension(9%).

Conclusions

This is the largest retrospective study of pediatric stroke of its kind from hospitals across the US in both academic and non-academic clinical settings. Many traditional adult risk factors for stroke are prevalent in pediatric patients with ischemic and hemorrhagic stroke, while common comorbidities in pediatric stroke diagnosed in academic centers, such as Moyamoya, congenital heart disease, and coagulation defects are less frequently diagnosed. A prior diagnosis of trauma and malignancy are prevalent in pediatric patients with both ischemic and hemorrhagic stroke.

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