Winter 2009

Predicting and Preventing Recurrent Stroke in Children

Heather Fullerton, M.D.

Pediatric vascular neurologist Heather Fullerton, M.D., says cerebrovascular imaging should be part of any post-stroke treatment protocol for children. Her belief is rooted in both her clinical experience and a study she recently completed with her colleagues at UCSF and the Kaiser Permanente Division of Research.

After looking retrospectively at the records of 181 cases of arterial ischemic stroke, the study — which appeared in the March 2007 issue of the journal Pediatrics — found that post-stroke imaging studies revealed cerebrovascular abnormalities in one in five otherwise healthy children. Two-thirds of those children had a recurrent stroke within five years, but patients with normal images had no recurrences at all.

"We demonstrated that cerebrovascular imaging accurately predicts risk and can help prevent recurrent stroke in children," says Fullerton, who directs the Pediatric Stroke and Cerebrovascular Disease Center at UCSF Benioff Children's Hospital.

New Techniques Change the Picture

Cerebrovascular imaging is already a common procedure with adult stroke patients, but it is only inconsistently prescribed for children. Perhaps this is due to risk concerns around angiograms, yet Fullerton points out that advances in noninvasive imaging techniques have significantly reduced the risks. "At most tertiary care centers, we can now visualize blood vessels, using techniques like MR angiography," says Fullerton. Other options include CT angiography and transcranial Doppler to attain dynamic images and identify narrowing by measuring velocity.

"The important points are that otherwise healthy children can have arteriopathy, that early recurrence is common in this population and that we have noninvasive ways to accurately predict that risk," says Fullerton.

Once at-risk patients are identified, managing the arteriopathy depends on understanding the type and the severity of the condition — and then treating it progressively with everything from antithrombotic medications to endovascular intervention and surgical revascularization. The complexity of doing so and the associated risks make treatment at specialized stroke centers essential.

For example, a center like the Pediatric Stroke and Cerebrovascular Disease Center uses a unique team approach. Fullerton — who is one of very few child neurologists in the country with expertise in vascular neurology — works closely with similar leaders in disciplines that range from hematology and neurosurgery to neurointerventional radiology and pediatric anesthesiology. The team convenes weekly meetings to discuss cases and review imaging, so they can present patients and their families with a fully informed range of treatment options.

"Every family deserves to hear all of the options, not just a single opinion from one specialty," says Fullerton.

To improve those options, a team at the center has submitted a grant to conduct a large, multicenter study that would establish recurrence rates and determine who, exactly, is at risk. "Once we've conclusively determined who is at risk, we can design a secondary stroke prevention study," says Fullerton.

For more information, contact Heather Fullerton, M.D. at (415) 353-3681.

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