COVID-19 and pediatric stroke—is there a connection?

One of our earliest pediatric mechanical thrombectomy cases at UCSF Benioff Children’s Hospital was during the 2003 SARS global outbreak.  Some of you may remember how children suffered more severe respiratory illnesses with that other coronavirus, and how thrombophilia was an anecdotal feature of the disease.  A toddler in our pediatric ICU with SARS pneumonia developed a large clot in her left ventricle.  While agitated during an IV placement, she suddenly stopped moving the right side of her body: the clot was gone from her heart, and instead she had complete blockage of her basilar artery and left internal cerebral artery.  Our interventional neuroradiologists successfully removed the clots—despite the more primitive devices of the day—and she survived with motor deficits.  That case stimulated my interest in the role of infection as a trigger for childhood arterial ischemic stroke, and ultimately led to our IPSS-run multicenter VIPS (Vascular effects of Infection in Pediatric Stroke) study.  Many of you helped enroll the >700 children in the VIPS study that demonstrated that minor acute infections—mostly upper respiratory infections—can transiently increase stroke risk.  Infection can trigger cardioembolic stroke in children predisposed by congenital heart disease; it can also trigger arteriopathic and idiopathic stroke in otherwise healthy children.   Serological analyses in VIPS found that many of the infections triggering pediatric stroke were subclinical.   So…what about COVID-19?  Emerging reports of adult cases suggest an infection-related thrombophilia, reminiscent of 2003 SARS.  Children have milder (or no) acute infectious symptoms, but could they still suffer para- or post-infectious complications?  Our dermatology colleagues are seeing children with post-COVID “pernio-like” ischemic lesions of distal toes, thought to be a small-vessel vasculitis.  An April 23rd article in the lay press describes a flurry of young adults in New York with ischemic strokes after mild or asymptomatic infection.   Hmmm….

The VIPS II study has been enrolling new pediatric stroke cases over the past three years with the aim of identifying the specific pathogens triggering childhood stroke; it will use next-generation sequencing of nucleic acids to identify pathogens in throat swabs and blood samples.   We successfully obtained permission to continue enrolling in VIPS II through the COVID-19 pandemic, so might eventually know whether this new coronavirus, SARS CoV-2, is a trigger.  In the meanwhile, we will be following the literature closely and blogging about relevant emerging evidence.  Please let us know if you become aware of any COVID-related pediatric strokes, or new papers that we might have missed.  And consider submitting an IPSO blog post yourself!

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Links to Relevant Scientific Publications:

VIPS paper on clinical infections as a trigger for childhood stroke
https://www.ncbi.nlm.nih.gov/pubmed/26423434

VIPS paper on subclinical herpesvirus infection as a trigger for childhood stroke
https://www.ncbi.nlm.nih.gov/pubmed/26813104

Early publication on pernio-like lesions in children after COVID-19
https://www.ejpd.com/images/acroischemia-ENG.pdf?fbclid=IwAR0BRRl6pX0DwD7RzQKI-Nbgo-LkfSYgGGA8maMtY7fh2BMjU6Sqmzle6BY

Papers on thrombotic complications in adult patients with coronavirus infections
https://www.ncbi.nlm.nih.gov/pubmed/32305883
https://www.ncbi.nlm.nih.gov/pubmed/32291094

Links to Relevant Lay Press Articles:

CNN Health article describing five young adults with COVID-19 related ischemic strokes at Mount Sinai Hospital in New York (April 23, 2020) https://www.cnn.com/2020/04/22/health/strokes-coronavirus-young-adults/index.html