Assessment of Risk Factors for Cerebrovascular Accidents in Children with Congenital Heart Diseases
Authors: Ali Nehal Khalil Ahmed , Hassanein Sahar Mohamed Ahmed , Ahmed Khaled Aboulfotouh , Guindy Waleed Mohamed El , Midany Ashraf Abd El Hamid El 
Published: November 2024

Abstract

Background
Children with congenital heart disease (CHD) are at an increased risk of cerebrovascular accidents (CVA), including arterial ischemic stroke (AIS), cerebral venous sinus thrombosis (CVST), and hemorrhagic stroke. The risk varies depending on age, comorbidities, underlying cardiac defect, and other factors, such as changing hemodynamics, cardiac procedures, and the need for mechanical circulatory support devices.

Aim
To determine the risk factors and neurological outcome of cerebrovascular accidents, that occur either spontaneously or peri-procedurally in children with congenital heart diseases.

Patients and Methods
A retrospective case-control study was conducted on the records of 72 patients collected from the patients' files between 2015 and 2023 at the Pediatric Neurology Clinic, and Pediatric Cardiology Clinic, Children's Hospital, Cardiothoracic Surgery Academy, Radio-diagnosis Department, Faculty of Medicine, Ain Shams University Hospitals with age ranged from 2 months to 18 years. Children with CHD and radiologically confirmed CVA (case group) were compared to CHD children without CVA (control group).

Results
Seventy-two children with CHD were included, 30 of whom had radiologically confirmed CVA (case group), and the remaining studied children (42 patients) who had CHD without CVA (control group). In the case group, they were 12 females (40%) and 18 males (60 %), 29 females (69%) and 13 males (31%) in the control group. The age at diagnosis of CVA in case group ranged from (2 months to 1 year) in 17 patients (56.7%), (2 – 6 years) in 7 patients (23.3%), and(7 – 12 years) in 3 (10.0%),and (13 – 18 years) in 3 (10.0%). Males in patients with stroke (60.0%) than in patients without stroke (31.0%) with p-value = 0.014. Twenty-four (57.1%) without stroke and 15 (50.0%) with stroke had acyanotic cardiac disease with the most common being VSD in 7 (23.3%) of those with stroke. there was no statistically significant difference between patients with and without stroke regarding cardiac cyanotic and acyanotic cardiac diagnosis. Twenty-one (70%) out of 30 were diagnosed AIS, 2 (6.7%) CVST, and 7 (23.3%) with hemorrhagic stroke. Stroke occurred following cardiac procedures in 20 patients (66.7%): 15 after cardiac surgery and 5 after cardiac catheterization. Risk factors for CVA were high blood pressure at admission in 12 patients (16.7%), hypoperfusion in 7 patients (9.7%), thrombus on the tip of central venous line (CVL) in 2 patients (2.8%), deep vein thrombosis (DVT) in 1 patient (1.4%), a hypercoagulable state in 1 patient (1.4%), high hematocrit level in 1 patient (1.4%), previous brain insult in 2 patients (2.8%), intracardiac mass in 1 patient (1.4%), infective endocarditis in 2 patients (2.8%), abnormal heart valve in 1 patient (1.4%), disseminated intravascular coagulation (DIC) in 1 patient (1.4%), and chronic disease in 10 patients (13.9%). Taking into consideration that more than one risk factor was found in the same patients. The results revealed that there was a statistically significant increase in the percentage of risk factors in patients with stroke (66.7%) than in patients without stroke (26.2%) with p-value = 0.001.

Conclusions
Individuals with CHD are at a higher risk of CVA, and this suggests that the risk assessment for CVA based on conventional cardiovascular risk factors should be considered in these patients. Early diagnosis of CHD is important to prevent further recurrences of stroke, and because they are potentially curable. Prospective cohort studies are required to determine effective primary and secondary prevention strategies.