Arterial ischemic stroke
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Understanding Arterial Ischemic Stroke: Risk Factors, Genetic Links, and Management
Introduction to Arterial Ischemic Stroke
Arterial ischemic stroke (AIS) occurs when a blood clot obstructs an artery supplying blood to the brain, leading to tissue damage. This condition can affect individuals of all ages, including neonates, children, and adults, and is associated with significant morbidity and mortality.
Risk Factors for Arterial Ischemic Stroke
Shared Risk Factors with Intracerebral Hemorrhage
Research indicates that intracerebral hemorrhage (ICH) and arterial ischemic events share common risk factors. A study analyzing data from four population-based cohort studies found that individuals with a history of ICH had a significantly higher risk of subsequent ischemic stroke and myocardial infarction. The hazard ratios for ischemic stroke and myocardial infarction were 3.1 and 1.9, respectively, suggesting that ICH may serve as a novel risk marker for arterial ischemic events.
Genetic Susceptibility
Genetic factors also play a crucial role in the risk of AIS. A meta-analysis of the 20210G>A polymorphism in the Factor II gene revealed that carriers of the 20210A allele have a higher likelihood of experiencing AIS. This association was significant in both children and young adults, with odds ratios of 1.83 and 1.69, respectively. Additionally, a genome-wide analysis identified several loci that are common to both ischemic stroke and coronary artery disease, indicating a shared genetic susceptibility.
Pediatric Risk Factors
In children, the risk factors for AIS can be diverse. The Canadian Pediatric Ischemic Stroke Registry highlighted that arteriopathy, cardiac disorders, and prothrombotic conditions are predominant risk factors in older children, while many neonates present with no discernible risk factors. Other studies have identified congenital heart malformations, sickle cell disease, and infections such as Varicella as significant contributors to pediatric AIS .
Epidemiology and Outcomes
Incidence and Presentation
The incidence of AIS varies across age groups. In children, the incidence is approximately 1.72 per 100,000 per year, with a higher rate in neonates at 10.2 per 100,000 live births. Common clinical presentations include seizures in neonates and focal deficits in older children. In adults, the incidence of AIS with visible arterial occlusion is about 37 per 100,000 per year, with a significant proportion involving the anterior circulation.
Long-term Outcomes
Long-term outcomes of AIS can be severe, particularly in children. Neurological deficits are common, affecting 60% of neonates and 70% of older children. Recurrent strokes or transient ischemic attacks occur in about 12% of older children, with arteriopathy and lack of antithrombotic treatment being significant predictors.
Management and Treatment
Pediatric Treatment Approaches
Treatment strategies for pediatric AIS are often adapted from adult protocols due to the lack of evidence-based guidelines for children. Low-dose aspirin is commonly used and considered relatively safe. Anticoagulation with heparins or warfarin may be indicated in cases of cardioembolic stroke or persistent hypercoagulable states. Blood transfusions are recommended for patients with sickle cell disease.
Adult Treatment Guidelines
For adults, the American Heart Association/American Stroke Association provides comprehensive guidelines for the early management of AIS. These guidelines emphasize the importance of prehospital care, urgent evaluation, and treatment with intravenous and intra-arterial therapies. Secondary prevention measures are also recommended within the first two weeks post-stroke .
Conclusion
Arterial ischemic stroke is a complex condition with multifactorial risk factors, including genetic predispositions and shared risk factors with other cardiovascular events. Understanding these risk factors and implementing appropriate management strategies are crucial for improving outcomes in both pediatric and adult populations. Continued research and clinical trials are essential to develop age-appropriate treatments and improve the prognosis for AIS patients.
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