Impact of Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation Classification on Further Course of Arteriopathy and Recurrence of Childhood Stroke

Background and Purpose— Arterial ischemic stroke (AIS) in childhood is a severe disease with potentially lifelong restrictions. Apart from cardiac or prothrombotic embolism, arteriopathy has been identified as a major cause and significant target of secondary stroke prevention. The Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation (CASCADE) criteria facilitate a structured tool for categorizing and reporting childhood strokes according to the underlying cause. Our study aims to identify the prognostic value of CASCADE classification on admission for further course of arteriopathy and risk of stroke recurrence. Moreover, we give recommendations for follow-up imaging based on different CASCADE subgroups. Methods— Between 2004 and 2017, we identified 86 children with an acute arterial ischemic stroke classified in the 7-basic and 19-expanded subgroups of the acute CASCADE criteria. All included children were diagnosed and followed-up by magnetic resonance imaging. All arteriopathic strokes (basic subgroups 1–4 of acute CASCADE criteria) were further categorized into the chronic CASCADE criteria, including progressive, stable, reversible, and indeterminate course. Outcomes were defined as stroke recurrence and course of arteriopathy according to chronic CASCADE criteria. Associations between acute CASCADE criteria classification and stroke recurrence were assessed by Fisher exact test and between acute CASCADE criteria and chronic CASCADE criteria by Fisher exact test and Mann-Whitney U test. Results— A total of 86 children were included; of these, 57 presented with arteriopathic stroke (CASCADE 1–4) and 29 as nonarteriopathic. Unilateral cerebral arteriopathy (CASCADE 2; P=0.036) and bilateral cerebral arteriopathy (CASCADE 3; P=0.016) significantly correlated with stroke recurrence, and progressive arteriopathy significantly correlated with unilateral focal cerebral arteriopathy (P<0.001). Time points of progress of arteriopathy differed; whereas patients with unilateral focal cerebral arteriopathy presented with early median progress after 11 days, patients with bilateral cerebral arteriopathy had a significantly later median progress after 124 days (P=0.005). Conclusions— Initial CASCADE classification is associated with risk of recurrent strokes and progress of arteriopathy. Moreover, time points of arteriopathic progress vary according to the underlying cause.