Pediatric Neuroscience Pathways Fall 2012 - Cleveland Clinic

Pediatric Stroke: Coming of Age
Neil Friedman, MBChB
after more than a century of descriptive studies in pediatric
stroke, the first interventional treatment trial for arterial ischemic
stroke is taking place. the thrombolysis in Pediatric stroke
(TIPS) Trial is a long-awaited five-year, multisite international
study funded by the NIH. It is a safety and dose-finding study of
intravenous tPa in children with acute arterial ischemic stroke
(AIS) (clinicaltrials.gov/ct2/show/NCT01591096?term=pediatric+
stroke&rank=1).
the start of the 21st century saw the beginnings of a remarkable
collaborative effort in pediatric stroke. the international Paediatric
stroke study (iPss) was established in 2003 as an international
registry with the long-term goal of developing a multicenter clinical
research and trials network focused on pediatric stroke and
outcomes. the iPss also has led to the development and establishment
of pediatric stroke centers throughout the world with the aim
of promoting an increasing awareness of pediatric stroke, more rapid
and comprehensive evaluation of ais and the development of
pediatric stroke protocols (app3.ccb.sickkids.ca/cstrokestudy/).
The first funded trial utilizing the IPSS network investigated the
application of a modified pediatric NIH stroke scale in acute AIS in
children. it was funded by the Nih and was a multicenter prospective
cohort study involving 15 North american sites between
January 2007 and October 2009. 2 A second, more ambitious study
investigating the association between infection and vasculopathy in
arterial ischemic stroke in children is in the final year of enrollment. 3
this too was funded by a grant through the Nih.
Pediatric Neurology
“a large number of cases of infantile cerebral palsy are caused by the same factors that bring about the majority
of cases of cerebral paralysis of adults: tearing, embolism and thrombosis of cerebral vessels.”
— Sigmund Freud, 1897 1
the role of arteriopathy
“No agreement has been reached so far as to the importance to be
ascribed to general and special vascular factors.”
—Sigmund Freud, 18971 Arteriopathies account for about one-third of childhood AIS and
have been identified as an important target for research. Etiologies
include genetic, infectious, inflammatory, traumatic and “iatrogenic”
(e.g., postirradiation) causes (Table 1). In an elegant study
by Fullerton et al, 4 the incidence of stroke recurrence risk was 66
percent in the presence of an arteriopathy, as compared with
approximately 20 percent in “all comers,” underscoring the need
for appropriate vascular imaging and stroke prevention studies.
the tiPs trial marks the coming of age of pediatric stroke and
is a testament to the dedication of purpose and collaboration of
such entities as the iPss and european collaborative groups.
reFereNces
1. Freud s. infantile cerebral paralysis (translated by la russin).
Coral Gables, FL: University of Miami Press; 1968:181.
2. Ichord RN, et al. Interrater reliability of the Pediatric National
institutes of health stroke scale (PedNihss) in a multicenter
study. Stroke. 2011;42:613-617.
3. Fullerton HJ, et al. The Vascular Effects of Infection in Pediatric
stroke (viPs) study. J Child Neurol. 2011;26:1101-1110.
4. Fullerton HJ, et al. Risk of recurrent childhood arterial ischemic
stroke in a population-based cohort: the importance of
cerebrovascular imaging. Pediatrics. 2007;119:495-501.
22 Pediatric NeuroscieNce Pathways | 2012 – 2013