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This paper reviews the epidemiology of childhood stroke. Stroke is an important condition
in children. It is one of the top ten causes of childhood death and there is a high risk of
serious morbidity for the survivors. Epidemiological data are an integral part of disease
14 September 2009
understanding and high quality studies are required to ensure that this data is robust.
Incidence rates from population-based studies vary from 1.3 per 100,000 to 13.0 per 100,000.
Factors found to influence incidence rates include age, gender, and ethnicity but there are
Keywords:
also many inherent differences between studies. Temporal analysis of mortality rates from
Child
childhood stroke shows falling rates but there has been little long-term study of changes in
Epidemiology
incidence rates. Improved epidemiological data should be a goal of the national and
Incidence
Mortality
2009 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights
Stroke
reserved.
Contents
1.
2.
3.
4.
5.
6.
7.
8.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ethnicity and geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Temporal trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
198
198
198
200
201
201
202
203
203
203
198
1.
Introduction
2.
Incidence
3.
Mortality
Gudmundsson
1977
Location
19
Giroud11 1995
Earley10 1998
Al-Rajeh90 1998
Beran-Koehn91
1999d
DeVeber18 2000d
Fullerton13 2003
Rochester,
Minnesota, USA
Linkoping, Sweden
Tohoku, Japan
Greater Cincinnati,
USA
Dijon, France
Baltimore and
Washington DC,
USA
Eastern Province
of Saudi Arabia
Rochester,
Minnesota, USA
Canada
California, USA
UK and Eire
Kirkham16 2003d
Chung and Wong15 2004 Hong Kong
Barnes et al.32
2004d
Steinlin17 2005d
Zahuranec
et al.49 2005
Kleindorfer
et al.20 2006d
Ghandehari92
2007
Melbourne,
Australia
Switzerland
Nueces County,
Texas, USA
Greater Cincinnati
metropolitan
area, USA
Mean annual
Person years Number of M:F ratio
population at risk
studied
cases
3.1
1.9
8.1
2.5
Yes
2.1
0.2
1.2
1.5
2.7
Yes
No
Yes
7.9
0.6
5.1
0.7
13.0
1.3
No
Yes
Yes
No
1.5
Yes
1.3
1.1
2.3
Yes
1.38
1.28
2.6
1.2
2.3
No
Yes
No
Yes
239
94
1.39
NR
0.8 (ICH),
0.4 (SAH)
1.94
2.1
Yes
Yes
Yes
Yes
5,400,000
98
1.71
1.8
No
No
1,270,000
92,418
3,800,000
180,000
80
8
2.08
1.0
2.1
1.1
4.3
Yes
Yes
No
Yes
286,000
570,000
16
2.7 (ICH),
0.5 (SAH)
2.8
Yes
Yes
306,000
277,000
310,000
280,000
3.6
5.4
Yes
Yes
Yes
Yes
980,000
0.8
1.43c
196,000
11b
15b
54
18
1.83
No
No
0 to <15 yr
65,184
720,000
22
15 to <20 yr
0 to <15 yr
16,826
15,834
190,000
160,000
15
4
0.6
0 to <15 yr
23,400
230,000
0 to <16 yr
0 to <15 yr
2,400,000
295,577
24,000,000
590,000
48
16
1.0
1.29
0 to <16 yr
1 to <15 yr
23,877
773,016
210,000
1,500,000
28
20
1.15
0 to <24 yr
334,000
1,000,000
15
28 d to <15 yr
14,000
560,000
13
0 to <18 yr
30 d to <20 yr
3,970,000
9,907,432
24,000,000
99,000,000
620
2278
11,370,000
1,136,325
12,000,000
4,500,000
681,000
0 to <17 yr
>1 month
to <20 yr
0 to <15 yr (19881989)
0 to <15 yr (19931994)
0 to <15 yr (1999)
0 to <16 yr
>1 month
to <15 yr
0 to <20 yr
Included
Yes
Schoenberg28
1978
Eeg-Olofsson27
1983
Satoh12 1991
Broderick78 1993
Iceland
Age range
CVT cerebral venous thrombosis; SAH subarachnoid haemorrhage; NR not reported on cases used for calculation of incidence.
a Unable to be determined from published paper.
b Data in addition to that published in the paper provided by Dr Kleindorfer.
c Male to female ratio of underlying <15 yr old population was 1.44.
d Mean annual population at risk was not available in published paper but was calculated by AAM.
199
200
4.
Age
Fig. 1 Mean incidence of childhood stroke and 95% confidence intervals. If figures were available in the published papers
for 95% confidence intervals they were used for this figure. If not available they were calculated by AAM using the Poisson
distribution for studies with less than 100 cases and the normal approximation for studies with 100 or more cases.89
5.
Gender
201
6.
The epidemiology of childhood stroke has not been extensively studied outside of highly developed nations with only
two of the studies listed in Table 1 being within less
economically developed countries. The studies in developed
nations are almost all of relatively homogenous, predominantly white Caucasian populations. The notable exceptions
are the studies by Satoh et al.12 and Chung and Wong15 which
studied populations that are almost exclusively (>98%) Japanese and Chinese respectively. The US studies have less
homogenous populations with variable proportions of children of mainly white, Hispanic, African-American, or Asian
ethnicity. For example, the baseline population in Kleindorfers study20 was 82% white and 15% African-America, whereas
it was 43% white, 39% Hispanic, 10% Asian and 7% AfricanAmerican in Fullertons study.13 Although there have been
studies of childhood stroke in other population groups they
have typically been small and not population based and,
therefore, have not been able to rigorously estimate the incidence of stroke.6062
The range of aetiological factors associated with childhood
stroke is very wide.63,64 It is very likely that the rates of many
of these factors are very different in different parts of the
world and hence, the epidemiology is also likely to be
different. For example various hospital based series of childhood stroke have found higher rates of associated infection in
Saudi Arabia,65 moyamoya in Taiwan,66 and sickle cell disease
in Brazil67 than is typically seen in Western Europe58 or North
America.13 It should be noted that, due to moyamoya being
relatively common in Japan, Satoh considered it as a special
entity of cerebrovascular disease and excluded cases from the
study of stroke incidence in Japan.12 Reported rates of risk
factors are likely to be heavily influenced by the type and
range of investigations that are performed in order to elucidate aetiology. As there is no universally agreed protocol for
the investigation of childhood stroke, large variations in the
202
7.
Temporal trends
1999 showed a non-significant trend towards increasing incidence over time.20 There was a non-significant decrease in
case mortality rate from the 19881989 period to the 19931994
period and no change between the 19931994 and 1999
periods. Data from the Canadian Pediatric Ischemic Stroke
Registry may also show increasing stroke incidence since the
establishment of the registry in 1992.79 However, a decade is
a short time period within which to examine such temporal
trends and there is a risk that apparent rising incidence may
be due to an ascertainment bias on account of improving case
ascertainment with time.
An interpretation of a rising incidence rate may be that
children are truly more likely to suffer a stroke than in the
past. Alternatively, increasing use of sophisticated diagnostic
tools may be increasing the recognition and diagnosis of
childhood stroke.80 For example, Kleindorfer found that the
use of CT increased between the 19931994 period and the
1999 period in the Cincinnati study.20 A number of the studies
that have estimated the incidence of childhood stroke19,28
collected cases prior to the ready availability of CT neuroimaging in the late 1970s to early 1980s. Perhaps more
importantly, MRI and newer MRI modalities such as perfusion,
gradient echo, and fluid attenuated inversion recovery
imaging are being used with increased frequency in childhood
stroke.81 Of particular note is diffusion weighted MRI which
has very high sensitivity for cerebral infarction, even within
a few minutes of the insult.82 The incidence of conditions that
mimic the presentation of stroke is unknown but it is likely to
be high.25 Although one study found that less than a quarter of
children who are referred with suspected stroke to a well
established stroke team were ultimately given another diagnosis, MRI was frequently required to differentiate stroke
from stroke mimics even in cases with an abnormal CT scan.83
Hence, increased use of MRI and associated neuroimaging
techniques may have the effect of increasing the apparent
incidence of childhood stroke by facilitating more frequent
diagnosis.75
Another factor that may facilitate recognition and diagnosis of childhood stroke is heightened awareness,81 amongst
both the general population and medical professionals.
Intensive stroke awareness programmes in a number of
countries have probably increased the awareness of stroke
and its symptoms in the general population.84,85 There are
now a number of national and international collaborative
groups studying childhood stroke79,86 and the number of
published articles on the subject of childhood stroke has been
steadily rising which is likely to lead to greater awareness
amongst medical professionals. Papers found on PubMed
using the search terms stroke AND children make up
a rising proportion of the total number of indexed papers. The
proportion in the 1970s was 9 per 100,000 papers, 32 per
100,000 in the 1980s, 43 per 100,000 in the 1990s and 55 per
100,000 from 2000 to 2008.87
Increasing survival of children with conditions known to
predispose to stroke such as complex congenital heart
disease, meningitis and malignancy may be a factor that
contributes to a true rise in the incidence of childhood
stroke.75 However, increased awareness of these risk factors
and improved management of conditions such as sickle cell
disease may ameliorate any such rise in incidence.88
8.
Summary
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Acknowledgements
Both of the authors are contributors to a prospective study of
childhood stroke funded by the Stroke Association (UK). The
funding source had no involvement in study design; in the
collection, analysis, or interpretation of data; in the writing of
the report; or in the decision to submit the paper for publication.
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