Published Online
on December 28, 2006

A more recent version of this article appeared on February 1, 2007

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Submitted on June 1, 2006
Revised on August 23, 2006
Accepted on September 13, 2006

Mode of Onset Predicts Etiological Diagnosis of Arterial Ischemic Stroke in Children

Kees P.J. Braun MD, PhD; Mubeen F. Rafay MBBS; Cuno S.P.M. Uiterwaal MD, PhD; Anne-Marie Pontigon Hon, BSc; and Gabrielle DeVeber MD, MSc^*

From Department of Child Neurology (K.P.J.B.), Wilhelmina Children’s Hospital, Rudolf Magnus Institute of Neuroscience; Julius Center for Health Sciences and Primary Care (C.S.P.M.U.), University Medical Center Utrecht, The Netherlands; Division of Neurology, Department of Pediatrics (M.F.R., G.D.), Population Health Sciences Program (A.M.P., G.D.), The Hospital for Sick Children, Toronto, Ontario, Canada.

^* To whom correspondence should be addressed. E-mail: deveber{at}sickkids.ca.

Background and Purpose--In children, early differentiation among various etiologies of arterial ischemic stroke (AIS) is important. Cerebral arteriopathy is a frequently identified cause of childhood stroke. Children with arteriopathies require a different therapeutic approach from children with AIS of nonarteriopathic origin. We aimed to investigate the association between temporal features of the onset of neurological symptoms and stroke etiology in children with AIS.

Methods--From a consecutive cohort of children (6 months to 18 years) with a confirmed diagnosis of AIS at one center, we selected all patients with transient cerebral arteriopathy (n=10), postvaricella angiopathy (n=20), dissection (n=8), cardio-embolic (n=8), and cryptogenic stroke (n=10). We retrospectively reviewed medical charts for mode of onset and classified the onset as either abrupt, reaching maximum severity of symptoms within 30 minutes, or nonabrupt, including a progressing, stuttering, or recurring course. We compared the mode of onset in patients with known cerebral arteriopathy to those with nonarteriopathic stroke using multivariate logistic regression modeling.

Results--There were no significant differences for age, gender, location of infarction, seizures, and headache between the arteriopathic and nonarteriopathic group. Most children with nonarteriopathic AIS had an abrupt onset (72%), compared with 32% in children with arteriopathic stroke. With nonabrupt onset, the odds of having an arteriopathic etiology was 6.1 (95% CI, 1.6 to 22.8; P=0.007) after correction for possible confounders.

Conclusions--Mode of onset predicts etiological diagnosis of childhood AIS and may guide prioritization of ancillary investigations and choice of treatment. A nonabrupt onset of symptoms is associated with arteriopathic stroke, particularly with presumed inflammatory arteriopathies.

Key words: child • embolism • intracranial arterial disease • ischemic stroke subtypes

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