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Editorials
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Predicting risk for recurrence of arterial ischemic stroke in children: thrombophilia as another piece of the puzzle
Ghada Aborkhees and Lesley Gayle Mitchell
Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
E-mail: LESLEY GAYLE MITCHELL - Lesley.Mitchell@albertahealthservices.ca
doi:10.3324/haematol.2019.222695
Recurrent arterial ischemic stroke (AIS) is increasing- ly recognized as a significant cause of mortality and morbidity in the pediatric population. Identifying risk factors for recurrent AIS is essential for developing strategies for secondary stroke prevention. While multiple risk factors have been identified for AIS events, the only confirmed risk factor for initial AIS recur- rence is the presence of vasculopathy, particularly moy- amoya disease.1-3 In a meta-analysis, prothrombotic risk factors were found to be associated with AIS in pediatric patients.4 However, the role of thrombophilia as an inde- pendent risk factor for recurrent AIS has not been estab- lished due to a paucity of research in the area and the lack of statistical power in the published studies.
In the current edition of Haematologica, deVeber et al. report on an international prospective cohort study which recruited 894 pediatric patients from centers in Germany, Canada and the UK.5 The primary objective of the study was to determine the association of prothrombotic risk factors and/or underlying stroke subtypes with risk for recurrent stroke. The authors excluded asymptomatic strokes and transient ischemic attacks due to the differ- ence in underlying disease as well as the differing out- comes from symptomatic strokes. Sickle cell disease and moyamoya vasculopathies were also excluded as their
recurrence rates and risk factors differ from those of other subtypes of pediatric AIS. The authors report an overall AIS recurrence rate of 17.9% in the cohort studied. The study confirmed the association of vasculopathy as a risk factor for AIS recurrence. The novel approach in the cur- rent study was the examination of the role of throm- bophilia as an independent risk factor for AIS recurrence. Study patients were excluded if they had thrombophilic markers with established pathophysiological relevance such as homozygous protein C and homozygous antithrombin deficiency. Analysis of the study data showed that the following were independent risk factors for recurrence: antithrombin deficiency (hazard ratio 3.9; 95% confidence interval: 1.4-10.9), increased lipoprotein(a) (hazard ratio 2.3; 95% confidence interval: 1.3-4.1) and more than one prothrombotic marker (hazard ratio 1.9; 95% confidence interval: 1.1-3.2). The results obtained from this study highlight the importance of screening AIS cases for thrombophilia in order to identify the children at risk of AIS recurrence.
The reported study is a valuable addition to the previ- ous efforts to identify the risk factors for AIS recurrence. There are significant strengths of the study design. The first was the relatively large sample size, which provided adequate power to determine the association of pro-
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