32 patients (20 male,62,5%) who met all the inclusion criteria and gave informed consent were included in the study. The mean initial ischemic stroke age was 77,39 ± 61,93 months. Initial stroke age was grouped as early (≤ 60 months) and late (> 61 months) and 16 patients (50%) were included in the early group. The mean time passed from initial symptom to emergency room admission was 72,29 ± 158,2 hours (median = 15,5 hours). The mean follow-up interval of the study group was 85,44 ± 20,52 months and the mean age of the group at the time of the study (present age) was 162,62 ± 64,4 months. Demographic and clinical characteristics of the study group are presented in Table I and Table II.
Table I. Baseline characteristics of the study group |
| Mean ± s.s | Median(min-max) |
Initial stroke age (months) | 77,39 ± 61,93 | 66 (0,5-180) |
Time interval to hospital admission (hours) | 72,29 ± 158,2 | 15,5 (1-720) |
Follow up interval (months) | 85,44 ± 20,52 | 84 (60–121) |
Present age (months) | 162,62 ± 64,4 | 142,5 (62–300) |
| N (%) | |
Age at initial stroke (group) | ≤ 60 months | 16(50) | |
> 61 months | 16(50) | |
Presence of EEG abnormality | 14(43.7) | |
Regular physiotherapy treatment | 24(75) | |
Recurrence of stroke | 6(18.7) | |
Table II. Clinical characteristics of the study group | N(%) |
Presenting complaint (symptom/sign) | Restlesness | 3(4,8) |
Hemiparesis and/or hemiplegia | 26(42) |
Aphasia | 3(4,8) |
Seizure | 7(11,3) |
Altered state of consciousness | 3(4,8) |
Facial asymmetry | 12(19,4) |
Ataxia | 5(8,1) |
Memory loss | 2(3,2) |
Vertigo | 1(1,6) |
| Total | 62(100) |
Etiology | Unknown | 9(28,1) |
Cardiac disease | 5(15,6) |
Moya moya disease | 7(21,9) |
Thrombophilia | 5(15,6) |
Infection(VZV) | 1(3,1) |
Trauma | 1(3,1) |
CNS aneurysm | 1(3,1) |
Genetic dysmorphism | 2(6,3) |
Total | 32(100) |
Risk factors | Genetic syndrome (Down syndrome) | 1(2,2) |
Cardiac disease (Total) Surgery for secundum ASD | 12(26) 1 |
Surgery for Tetralogy of Fallot | 3 |
Fontan surgery for hypoplastic left heart | 1 |
Dilated cardiomegaly seconary to Parvovirus infection | 1 |
Surgery for pulmonary stenosis | 1 |
Surgery for coarctation of aorta | 1 |
Mitral valve disease secondary to ARF | 1 |
Patent foramen ovale | 2 |
Bicuspid aorta | 1 |
Pathological tests for hypercoagubility (Total) PAI gene homozygous mutation | 32(69,6) 3 |
Low protein C | 3 |
High Lipoprotein A | 2 |
Low Factor 8 | 1 |
MTHFR C677T heterozygous mutation | 9 |
MTHFR A1298C heterozuygous mutation | 8 |
Factor V Leiden heterozygous mutation | 1 |
High homosistein level | 4 |
High anti-thrombin 3 level | 1 |
Family history of stroke | 1(2,2) |
Total | 46(100) |
Radiological localisation territory of ischemic infarct | Anterior | 17(53,1) |
Posterior | 2(6,3) |
Widespread | 13(40,6) |
Total | 32(100) |
Vascular localization of ischemic stroke | MCA | 16(50) |
ICA | 1(3,1) |
PCA | 1(3,1) |
Vertebral artery | 1(3,1) |
Multipl vessels | 13(40,7) |
Total | 32(100) |
Treatment modality | Antiplatelets (Aspirin) | 9(28,2) |
Anticoagulants | 5(15,6) |
Both antiplatelet (Aspirin) and anticoagulant | 8(25) |
Initial anticoagulant followed by antiplatelet | 8(25) |
Acute thrombectomy followed by antiplatelet(aspirin) | 1(3,1) |
No medical treatment | 1(3,1) |
Total | 32(100) |
Long term clinical outcome | Normal daily functions | 17(53,1) |
Motor dysfunction | 6(18,8) |
Cognitive dysfunction | 2(6,2) |
Motor and cognitive dysfunction | 7(21,9) |
Focal motor weakness (42%) and facial asymmetry (19.4%) were the most common presenting signs.
All the patients had undergone diffusion-weighted imaging (DWI) MRI and Cranial CT in the first two hours after hospital admission. Diagnostic Cranial MRI and cranial/cervical MRI angiography were performed in the first 48 hours after admission. MRI venography was performed on suspicion of venous thrombosis and fat-suppressed T1 axial MRI images were performed in patients with a trauma history to detect cervical arterial hematomas. Conventional angiography (DSA) was performed in 13 patients (40.6%). The major indications for DSA were undetermined etiology and findings of vasculopathy in the initial investigational studies.
The most commonly detected etiology was cardiac disease (37.3%) followed by moya moya disease (21.8%). Etiology was not detected in 28.1% of patients despite all investigational studies.
Four of the six recurrent stroke cases had cardiac etiology, and two of them had undetermined etiology despite all detailed investigations (genetic evaluation included chromosome analysis, CGH array and WES(whole exome sequencing))(Table II).
Motor deficit scored as 0–1 in the Modified Rankin Scale was included in the ‘Normal Daily function’ group(Table II).
Long-term prognosis was the main target criterion in all statistical analyses of the study. Long-term clinical outcome was grouped into four categories according to neurological examination and family reports: Group 1 (Normal daily functions), Group 2 (Motor dysfunction), Group 3 (Cognitive dysfunction), and Group 4 (Motor and cognitive dysfunction). Group 1 was considered as the best prognosis and group 4 was considered as the worst prognosis. PSOM-SNE was scored between 0–10 points and the results were also used for correlation with clinical classification.
Stroke Age
The late stroke age group (> 61 months) had a significantly higher rate of normal functional long-term outcome(p = 0.023, Chi-square test)(Table III).
PSOM-SNE scores of 17 patients who reported having normal daily functions (Group 1) revealed that only 4 patients had ‘0’ points and the rest 13 patients had minimal abnormalities specifically in language or cognitive and behavioral deficit areas which have been missed by neurological examination and parental questioning method.
PSOM-SNE scores of the younger stroke age group (≤ 60 months) were significantly higher than the late age group (> 61 months) and only two patients out of six with normal daily functions had zero points from PSOM-SNE scoring.
Table III. Relationship of long term outcome and stroke age |
| Stroke age group | P** |
≤ 60 months | > 61 months |
n | % | n | % |
Long term clinical outcome | Normal Daily functions | 6 | (37,5) | 11 | (61,1) | 0,023 |
Motor dysfunction | 2 | (12,5) | 4 | (22,2) |
Cognitive dysfunction | 1 | (6,3) | 1 | (5,6) |
Motor and cognitive dysfunction | 7 | (43,7) | 2 | (11,1) |
PSOM-SNE Scores (mean±SD) | 16 | 2,25±2,48 | 16 | 1,18±0,65 | 0,018 |
**Chi-square test |
Hospital admission time interval
The median time interval from the appearance of the first symptom to hospital admission was 24 (mean:33,5 ± 14,2) hours in the younger stroke age group (≤ 60 months) and 9 (mean: 105,07 ± 208,4) hours in the late age group (> 61 months). Patients who applied with nonspecific symptoms like restlessness and altered state of consciousness had longer hospital admission times in both groups.
Vascular territory
We did not find a statistically significant difference between first stroke age and vascular stroke territory (p = 0.176, Kruskal-Wallis test) (Table IV)
There was no statistical correlation between the presence of EEG abnormality at admission and vascular stroke territory (p = 0.94, Chi-square test)
The mean time interval to hospital admission was compared according to vascular stroke territory and a statistically significant difference was not found(p = 0.372, Kruskal Wallis test).
Statistical differences could not be found in terms of presenting complaints at hospital admission according to vascular stroke territory (p = 0.401,chi-square test).
Vascular territory also did not have any significant effect on long-term clinical outcomes (p = 0,550, Chi-square test)
Table IV. Stroke age and vascular territory |
| Stroke age (Months) | P* |
Meant ± SD | Median(min-max) |
Stroke vascular territory | Anterior | 66,97 ± 66,41 | 48 (0,5-180) | 0,176 |
Posterior | 25,5 ± 23,33 | 25,5 (9–42) |
Widespread | 99 ± 53,61 | 94 (2-180) |
*Kruskal-Wallis Test |
Anterior circulation was the most common vascular territory (62,5%) in the early age group however late age group had widespread stroke territory more commonly (56,25%) but the difference between the groups was not statistically significant (p = 0,108, chi-square test)
Table V Treatment strategy according to stroke vascular territory |
| Anterior | Posterior | Widespresd | P* |
n | % | n | % | n | % |
Treatment | Only antiplatelet | 2 | (11,8) | 1 | (50,0) | 6 | (46,2) | 0,376 |
Only anticoagulant | 3 | (17,6) | 1 | (50,0) | 1 | (7,7) |
Both antiplatelet and anticoagulant | 5 | (29,4) | 0 | (0) | 3 | (23,1) |
First anticoagulant followed by antiplatelet | 5 | (29,4) | 0 | (0) | 3 | (23,1) |
No treatment | 2 | (11,8) | 0 | (0) | 0 | (,00) |
Total | | 17 | | 2 | | 13 | | |
P* Chi-square |
Initial treatment strategy was planned according to etiology and risk factors rather than affected vascular territory and there was no significant difference according to affected stroke territory between the treatment groups (p = 0,376, chi-square).
Etiology
The etiology of the stroke did not have a statistically significant effect on long-term outcome (p = 0.088, Chi-square test).
Treatment strategy
Only antithrombotic treatment was the predominantly preferred treatment modality among patients with the best outcome (normal Daily functions)(p = 0.002,chi-square). Aspirin was the only antiplatelet drug used in our study population. Subcutaneous enoxaparin was the preferred anticoagulant in all patients.
One patient who had a stroke in the hospital after cardiac surgery underwent an emergent thrombectomy in our study population. His medical treatment was continued with only aspirin afterward.
All patients have stopped anticoagulant treatment after 6 months, however patients with cardiac etiology and Moya moya disease were still on antiplatelet treatment regardless of their clinical condition (Table V,VI)
Table VI. Relation of initial medical treatment with long term outcome |
| Long term outcome | P* |
Normal Daily functions | Motor dysfunction | Cognitive dysfunction | Motor and cognitive dysfunction |
n | % | n | % | n | % | n | % |
Treatment | Only antiplatelet | 8 | (47,06) | 0 | (,00) | 0 | (,00) | 1 | (11,11) | 0,002 |
Only anticoagulant | 1 | (5,88) | 3 | (50,00) | 0 | (,00) | 1 | (11,11) |
Both antiplatelet and anticoagulant | 5 | (29,41) | 3 | (50,00) | 0 | (,00) | 0 | (,00) |
First anticoagulant followed by aniplatelet | 3 | (17,65) | 0 | (,00) | 0 | (,00) | 5 | (55,56) |
No treatment | 0 | (,00) | 0 | (,00) | 0 | (,00) | 2 | (22,22) |
*Chi-square test |
Table VII. Treatment modalities according to etiology |
| Etiology (n,%) |
Moya Moya | Cardiac | Unknown | Genetic | Varicella | Trauma | Aneurism | Tumor |
Treatment | Only antiplatelet | 5 | 2 | | 1 | | | | |
Only anticoagulant | | | 2 | | | 1 | 1 | 1 |
Both Antiplatelet and anticoagulant | | 1 | 5 | | | | | |
First anticoagulantfollowed by antiplatelet | 2 | 2 | 2 | | 1 | | | |
No treatment | | | | 1 | | | | |
Total | | 7 | 5 | 9 | 1 | 1 | 1 | 1 | 1 |