Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study

Background: For childhood-onset arterial ischaemic stroke (AIS), treatment trials are lacking and practices vary from country to country and centre to centre. We aimed to describe frequencies and predictors of acute treatments and early outcomes in the International Pediatric Stroke Study (IPSS), a large international series of childhood AIS. Methods: The IPSS has 33 centres enrolling children with stroke. Data for children aged 28 days to 19 years with AIS from Jan 1, 2003, to Oct 1, 2007, were collected with standardised case-report forms and analysed to identify factors associated with stroke treatment and early prognosis. Findings: Among 661 children with AIS (640 with acute treatment data, 612 with morbidity data, and 643 with mortality data), acute treatments included anticoagulation alone in 171 patients (27%), antiplatelet therapy alone in 177 (28%), antiplatelet and anticoagulation in 103 (16%), and no antithrombotic treatment in 189 (30%). After adjustment for significant covariates, subtypes associated with any use of anticoagulation were dissection (odds ratio 14·09, 95% CI 5·78-37·01; p<0·0001) and cardiac disease (1·87, 1·20-2·92; p=0·01). Factors associated with non-use of anticoagulation included sickle-cell disease subtype (0·12, 0·02-0·95; p=0·04) and the enrolment centre being located in the USA (0·56, 0·39-0·80; p=0·002). By contrast, antiplatelet use was associated with moyamoya (4·88, 2·13-11·12; p=0·0002), whereas non-use was associated with dissection (0·47, 0·22-0·99; p=0·047), low level of consciousness (0·45, 0·31-0·64; p<0·0001), and bilateral ischaemia (0·32, 0·20-0·52; p<0·0001). Outcomes at hospital discharge included neurological deficits in 453 (74%) patients and death in 22 (3%). In multivariate analysis, arteriopathy, bilateral ischaemia, and decreased consciousness at presentation were prognostic of adverse outcome. Interpretation: Acute anticoagulation is commonly prescribed in acute childhood-onset AIS although practice varies with AIS subtype and geographical region. Several factors are prognostic of adverse early outcome, and clinical trials are needed to determine the best treatment strategies. Funding: Canadian Stroke Network; Auxilium Foundation; NIH NCRR; NIH NHLBI.