The size of the infarct and high blood glucose -- not high blood pressure or fever -- predicted which children would be left with moderate neurological deficits after an acute arterial ischemic stroke, a retrospective cohort review showed.
An infarct size of 4% or greater of brain volume had the strongest association with moderate disability, with an odds ratio of 5.6 (95% CI 2.0-15.4; P=0.001) for a score of 1 on the Pediatric Stroke Outcome Measure or worse compared with smaller infarcts.
The second strongest association with post-stroke disability was hyperglycemia in the first 5 days after onset (OR 3.9; 95% CI 1.2-12.4; P=.02), Lori C. Jordan, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues reported online in JAMA Neurology.
"In pediatric patients with acute arterial ischemic stroke, achieving euglycemia may be important," the researchers wrote.
While in adults, the literature supports control of blood pressure and glucose level following stroke, "it is critical to determine the role of this practice in children to help improve outcome," Jordan and colleagues wrote, noting that "Neurologists are asked how to manage these parameters as part of supportive care for every child with acute ischemic stroke."
This study's cohort was too small to draw definitive conclusions, Lauren A. Beslow, MD, of Yale University, said in an accompanying editorial. "Therefore, the present study is unable to answer questions asked at the bedside of nearly every child with stroke, such as, 'How should blood pressure be managed?'"
Beslow agreed that more work needs to be done using standardized definitions and measures for blood pressure, temperature and blood glucose levels in both the acute and follow-up care settings.
The finding that infarct volume was independently associated with poor outcome supports findings from other groups, she said, adding that abnormal vital signs and blood glucose levels in this study may have been more common than previously thought.
"This study acts as a reminder to those who care for children with stroke that vital sign changes and abnormal laboratory values could be critical, particularly because they may be modifiable," Beslow wrote. "Blood pressure, temperature, and blood glucose levels should be focuses for future study efforts in addition to efforts to prevent recurrence and promote recovery. This study should prompt multicenter prospective studies on each of these factors to improve existing guidelines for management after childhood arterial ischemic stroke."
For the review, researchers looked at 98 children between the ages of 29 days and 18 years admitted within 48 hours of onset of their first arterial ischemic stroke to Vanderbilt Children's Hospital. The median age of the patients seen from January 2009 and December 2013 was 6.0 years, and 59.2% were male.
For 5 days following the stroke, data on blood pressure, blood glucose, and temperature data were collected. Morbidity and mortality at 3 months also was documented and data analyses took place from July 1, 2014, to Dec. 31, 2015.
The researchers determined that:
- 65.3% of patients had hypertension, defined as systolic blood pressure at or above the 95th percentile for age, sex, and height for two consecutive recordings on two consecutive days
- 68.4% of patients had hypotension, defined as systolic and/or diastolic blood pressure below the fifth percentile for age, sex, and height for two consecutive recordings
- 18.1% of patients had hyperglycemia, defined as a blood glucose level of 200 mg/dL or greater
- 37.8% of patients had fever
Only 27.6% of the 87 surviving children didn't have high blood pressure at 3-month follow-up. Five children died of cardiac disease; six died of systemic illness.
However, the researchers noted, "Our study found no significant association between outcome and hypertension at 3 months after stroke, even with our more stringent definition."
This finding differs from that of a prior study that found that hypertension was associated with death but not poor outcome at 1 year. That study didn't include data on infarct volume or blood pressure at follow-up, they pointed out.
Jordan and colleagues acknowledged several limitations of their study. These included a lack of information about IV fluid dextrose content in relation to blood glucose measurements, lack of a standardized blood pressure measurement technique, the use of ICD-9 codes (known to have limitations in both sensitivity and specificity), and a study population primarily made up of children with cardiac disease.
"We believe that future studies should consider infarct volume when assessing predictors associated with outcome," the researchers wrote. "Prospective studies that systematically record blood pressure, blood glucose, and temperature data are required to further assess the associations between these potentially modifiable physiological parameters and pediatric stroke outcome."
No conflicts of interest were disclosed.
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