COVID-19 and Pediatric Stroke: What is the Connection?

Mar 3, 2021

By Lauren A. Beslow.

In May 2020, the New England Journal of Medicine reported a series of 5 young adult patients who presented to the same hospital in a two-week period with larger artery strokes as a presenting feature of COVID-19. This high profile NEJM correspondence and other cases of young adults with stroke and COVID-19 led to multiple news headlines like “Young and middle-aged people, barely sick with COVID-19, are dying of strokes.” Reports and news headlines led to calls from worried parents of our pediatric stroke patients asking if their children were at increased risk of recurrent stroke if infected with SARS-CoV-2. Emails among IPSO members circulated asking whether anyone had evaluated a pediatric patient with COVID-19 and stroke. Most of us had not! However, the emails and questions continued. The Publications Committee of the IPSS created a survey to determine numbers of incident pediatric ischemic strokes in the first three months of the pandemic compared to the previous two months and the number of pediatric strokes positive for SARS-CoV-2. This survey was distributed in June 2020 to IPSS membership as well as to members of the British Paediatric Neurology Association Cerebrovascular Interest Group. Sixty-one sites from 26 countries participated in the survey. We collected additional data from 41 centers in 20 countries regarding numbers of hospitalized pediatric patients with SARS-CoV-2.

The survey study results are published in Annals of Neurology, and all co-investigators are credited in the Appendix. We found that for pediatric patients 0 to ≤18 years hospitalized with evidence of SARS-CoV-2 infection, the risk of having and ischemic stroke is less than 1%. Also, fewer than 5% of pediatric patients with incident ischemic strokes that occurred between March and May 2020 had evidence of SARS-CoV-2 infection. We know that pediatric strokes are often multifactorial, and 7 of 8 cases of pediatric stroke with SARS-CoV-2 infection in our study had at least one other established risk factor for stroke. In the medical literature, there are other reported cases of pediatric stroke with SARS-CoV-2 infection that suggest a stronger link between the SARS-CoV-2 infection and the stroke. For example, in May 2020, a Lancet article described eight patients with a novel toxic shock-like syndrome characterized by fever, severe inflammation, and multisystem involvement known as multisystem inflammatory syndrome in children (MIS-C) or pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). This series of patients included one case who had a large stroke in the setting of extracorporeal membrane oxygenation. In July 2020, Mirzaee et al. reported a case of focal cerebral arteriopathy of childhood in a patient with COVID-19 and a positive SARS-CoV-2 PCR in the CSF. Our IPSO colleagues including Brian Appavu and Michael Dowling described two pediatric cases of large vessel occlusion and stroke several weeks after acute COVID-19. However, there are still few cases of pediatric stroke and SARS-CoV-2 reported overall, so it is not possible at this point to know the full extent of the relationship between SARS-CoV-2 and stroke in children. Possible stroke mechanisms for pediatric patients with SARS-CoV-2 include development of arteriopathy or arteritis, inflammation, increased risk of clot formation, and requirement for extracorporeal membrane oxygenation in some severe COVID-19-related acute respiratory distress syndrome or severe MIS-C/PIMS-TS with accompanying cardiovascular collapse.

It is well established that certain viruses that are risk factors for pediatric stroke, like varicella, can cause arteriopathies weeks to months after the initial infection. Therefore, some SARS-CoV-2-related arteriopathies and stroke cases could become evident at longer intervals after the infection. Also, SARS-CoV-2 infection rates are high in many areas, so a child could certainly have an asymptomatic or mild infection that is unrelated to the stroke. It is therefore important that we collect details about cases of pediatric stroke in the setting of SARS-CoV-2 infection in order to understand whether the viral infection is a contributing factor to the stroke or whether the infection is incidental.

We are now re-surveying our group to determine the proportion of pediatric SARS-CoV-2 hospitalized pediatric patients with childhood arterial ischemic stroke and the proportion of new cases of childhood arterial ischemic stroke with SARS-CoV-2 from June through December 2020. Knowing whether the numbers of pediatric stroke in the setting of SARS-CoV-2 infection remain the same or whether they increase (or decrease!) will help us understand the contribution of SARS-CoV-2 to pediatric stroke better.

In addition to our group providing useful data, one of the greatest rewards from conducting this study was witnessing firsthand the commitment of our pediatric stroke consortium to answering important questions, even under the toughest of circumstances. I also connected with new colleagues in the IPSO and BPNA and am grateful to work with so many wonderful friends.

Please consider filling out COVID-19 and Pediatric Stroke Survey II which will remain open through the International Stroke Conference and IPSS meeting in March 2021! The Link to the COVID-19 Pediatric Stroke Survey II that covers June-December 2020 is pasted below. You can open link or paste into your browser!

Noma Dlamini and I are happy to assist with any questions. Please email !

Lauren A. Beslow, MD, MSCE, FAHA

Lauren A. Beslow, MD, MSCE, FAHA

Children's Hospital of Philadelphia

Lauren A. Beslow is an attending physician in the Division of Neurology at Children’s Hospital of Philadelphia specializing in pediatric stroke. She is an active member of IPSO and IPSS.

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