Unveiling the Burden of Cardiovascular Disorders in Pediatric Stroke—Insights from Pakistan

Pediatric stroke, though relatively uncommon, poses significant clinical challenges due to its high rates of morbidity and mortality [1]. Its incidence varies with age, remaining lowest in children aged 5–9 years and rising notably among adolescents aged 10–18 years, excluding neonates [2]. Cardiovascular disorders—both congenital and acquired—are increasingly recognized as important contributors to pediatric stroke, functioning as direct etiological factors or underlying conditions. Globally, congenital and acquired heart diseases, particularly cyanotic lesions, are reported in 0.34% to 1.5% of the pediatric population [3], and defects such as atrial septal defects, patent ductus arteriosus, cardiomyopathies, and infective endocarditis have all been implicated in pediatric stroke pathophysiology [4]. Children with pre-existing cardiovascular pathology are at heightened risk of stroke, especially following cardiac surgeries or interventions. Moreover, emerging data underscores the rising impact of modifiable cardiovascular risk factors such as obesity and hypertension in children. Notably, nocturnal hypertension has been associated with elevated stroke risk in children with sickle cell disease, reinforcing the complex interplay between cardiovascular management and neurologic outcomes [5]. In low- and middle-income countries like Pakistan, the burden of pediatric stroke attributable to cardiovascular disorders remains underappreciated and under-investigated. Despite the considerable clinical and socioeconomic toll, there is a lack of population-specific data on the prevalence, risk factors, and outcomes associated with cardiac-related pediatric stroke [6]. This data gap limits the development of contextually relevant preventative and therapeutic strategies. Against this backdrop, the study by Muhammad Kamran and Saleem Akhtar titled “Prevalence and Impact of Cardiovascular Disorders in Children with Stroke” represents a timely and significant contribution [7]. Conducted at the Aga Khan University Hospital over a 15-year period (2008–2022), this retrospective analysis of 147 pediatric stroke cases provides a comprehensive account of the cardiovascular underpinnings of pediatric stroke in a developing country context. The study demonstrates that 39% of pediatric stroke cases had identifiable cardiovascular disorders, a figure that is consistent with international data and reinforces the critical need for focused cardiovascular assessment in pediatric stroke evaluations. Importantly, the authors stratify cardiovascular disorders into cyanotic and acyanotic congenital defects, as well as acquired conditions such as myocarditis, rheumatic heart disease, and cardiomyopathy. Tetralogy of Fallot and atrial septal defect emerged as common congenital contributors. Ischemic strokes were more prevalent than hemorrhagic ones, aligning with global patterns, while acquired cardiovascular disorders had a stronger association with hemorrhagic presentations. Additionally, the study notes significantly lower hemoglobin and hematocrit levels in children with acquired cardiac pathology, suggesting a role for anemia or volume depletion in potentiating stroke risk. The clinical outcomes are sobering: mortality was disproportionately high among children with cardiovascular disorders, with more than one-third of pre-discharge deaths occurring in this subgroup. These findings underscore the urgent need for systematic cardiovascular screening in children, particularly those with suspected or confirmed neurologic events. Incorporating echocardiographic evaluations and enhancing neonatal cardiac screening may facilitate early identification of at-risk patients. Furthermore, optimizing management of contributing factors such as anemia and hypertension—though less common than in adults—could offer additional protective benefits. While the study is limited by its retrospective design and single-center scope, it serves as a critical foundation for future work. Multicenter, prospective research exploring regional and socioeconomic variability, genetic predispositions, and long-term neurodevelopmental outcomes is essential. Such efforts would better inform clinical guidelines, rehabilitation strategies, and resource allocation. The work by Kamran and Akhtar clearly establishes cardiovascular disorders—especially congenital defects and cardiomyopathy—as central drivers of pediatric stroke in Pakistan. Their findings argue persuasively for an integrated, multispecialty approach that combines pediatric cardiology, neurology, and rehabilitation services. In resource-limited settings, this integration is both a challenge and a necessity. By illuminating these connections, the study contributes meaningfully to the global conversation on pediatric stroke and offers a compelling call to action for healthcare policy reform and clinical vigilance in low-resource environments [8-10]. References Beslow LA, Dowling MM, Hassanein SMA, Lynch JK, Zafeiriou D, Sun LR, et al. Mortality After Pediatric Arterial Ischemic Stroke. Pediatrics. 2018;141(5):e20174146. DOI: 10.1542/peds.2017-4146 Oleske DM, Cheng X, Jeong A, Arndt TJ. Pediatric Acute Ischemic Stroke by Age-Group: A Systematic Review and Meta-Analysis of Published Studies and Hospitalization Records. Neuroepidemiology. 2021;55(5):331-341. DOI: 10.1159/000518281 Hussain S, Sabir MU, Afzal M, Asghar I. Incidence of congenital heart disease among neonates in a neonatal unit of a tertiary care hospital. J Pak Med Assoc. 2014;64(2):175-8. https://pubmed.ncbi.nlm.nih.gov/24640808/ Beriwal N, Imran H, Okotcha E, Oraka K, Kataria S, Bhandari R, et al. Cardiovascular and Hematological Risk Factors and Mortality Risk in Pediatric Arterial Ischemic Stroke: Analysis Report From Hospitals in the United States. Cureus. 2020 Oct 9;12(10):e10859. DOI: 10.7759/cureus.10859 Strumph K, Hafeman M, Ranabothu S, Gomes W, Benitez S, Kaskel F, et al. Nocturnal hypertension associated with stroke and silent cerebral infarcts in children with sickle cell disease. Pediatr Blood Cancer. 2021;68(5):e28883. DOI: 10.1002/pbc.28883 Sinclair AJ, Fox CK, Ichord RN, Almond CS, Bernard TJ, Beslow LA, et al. Stroke in children with cardiac disease: report from the International Pediatric Stroke Study Group Symposium. Pediatr Neurol. 2015;52(1):5-15. DOI: 10.1016/j.pediatrneurol.2014.09.016 Ullah MK, Akhtar S. Prevalence and Impact of Cardiovascular Disorders in Children with Stroke. Pak Heart J. 2025;58(02):151-157. DOI: 10.47144/phj.v58i2.2835 Mackay MT, Wiznitzer M, Benedict SL, Lee KJ, Deveber GA, Ganesan V; International Pediatric Stroke Study Group. 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