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Stroke in Children With Cancer: The Tip of the Iceberg?

      We read with great interest the article by Noje et al.
      • Noje C.
      • Cohen K.
      • Jordan L.C.
      Hemorrhagic and ischemic stroke in children with cancer.
      in which they analyzed the incidence and characteristics of stroke in children with cancer. Among a population of 1411 children with cancer, during a 10-year period registry, 15 children had stroke, corresponding to an overall prevalence of 1%. A slightly increased prevalence of stroke in children with brain tumors was documented (1.3%). The occurrence of stroke in children with brain tumors is potentiated by cranial radiation therapy.
      • Campen C.J.
      • Kranick S.M.
      • Kasner S.E.
      • et al.
      Cranial irradiation increases risk of stroke in pediatric brain tumor survivors.
      We are currently following a cohort of 103 adult survivors of childhood primary central nervous system tumors in our neurooncology clinic.
      • Passos J.
      • Nzwalo H.
      • Marques J.
      • Azevedo A.
      • Nunes S.
      • Salgado D.
      Late cerebrovascular complications of radiation therapy for pediatric primary central nervous system tumors.
      They all underwent radiotherapy during childhood as part of their treatment protocol. Of these patients, two had stroke, grossly corresponding to a prevalence of 1.9%. This finding is consistent with the results presented by Noje et al.
      • Noje C.
      • Cohen K.
      • Jordan L.C.
      Hemorrhagic and ischemic stroke in children with cancer.
      The two stroke cases occurred at the age of 4 years—19 months after tumor treatment in one patient—and at the age of 25 years—20 years after tumor treatment in the other patient. In both patients, we identified additional silent cerebrovascular lesions (cavernomas and microbleeds). In our cohort, the overall prevalence of late cerebrovascular complications such as microbleeds, cavernomas, stroke, superficial siderosis, and moyamoya syndrome identified by magnetic resonance imaging was 34.0%. These complications appeared any time during the follow-up period (median of 18.7 years after radiation therapy).
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      References

        • Noje C.
        • Cohen K.
        • Jordan L.C.
        Hemorrhagic and ischemic stroke in children with cancer.
        Pediatr Neurol. 2013; 49: 237-242
        • Campen C.J.
        • Kranick S.M.
        • Kasner S.E.
        • et al.
        Cranial irradiation increases risk of stroke in pediatric brain tumor survivors.
        Stroke. 2012; 43: 3035-3040
        • Passos J.
        • Nzwalo H.
        • Marques J.
        • Azevedo A.
        • Nunes S.
        • Salgado D.
        Late cerebrovascular complications of radiation therapy for pediatric primary central nervous system tumors.
        J Neurol Sci. 2013; 333: e238-e239

      Linked Article

      • Hemorrhagic and Ischemic Stroke in Children With Cancer
        Pediatric NeurologyVol. 49Issue 4
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          Adult survivors of childhood cancer have an increased risk of cerebrovascular disease; little is known about early stroke risk in childhood cancer. Our objectives were to assess stroke prevalence in children with cancer, to establish cancer and stroke type, and to determine if modifiable risk factors for stroke were present.
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      • Response to Passos et al
        Pediatric NeurologyVol. 50Issue 2
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          We appreciate the letter from Drs. Passos, Nzwalo, and colleagues1 as well as their interest in our article, “Hemorrhagic and Ischemic Stroke in Children with Cancer.” They report important data on the long term rate of stroke and cerebrovascular disease in adult survivors of childhood primary central nervous system tumors followed in their neuro-oncology clinic at Centro Hospitalar do Algarve in Lisbon, Portugal. We applaud their efforts to carefully follow their patients longitudinally and assess for nonovert lesions such as microbleeds, cavernous malformations, superficial siderosis, and moyamoya.
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