Association Between Thrombectomy and Functional Outcomes in Pediatric Patients With Acute Ischemic Stroke From Large Vessel Occlusion

Abstract

ImportancePediatric large vessel occlusion (LVO) stroke has a poor natural history. However, uptake of mechanical thrombectomy is hindered by a lack of clinical trial data in children. A randomized clinical trial is not feasible due to small sample sizes and absence of equipoise.ObjectiveTo evaluate whether pediatric patients with acute LVO stroke who undergo thrombectomy have better clinical outcomes than matched patients managed conservatively.Design, Setting, and ParticipantsThis matched case-control study used pooled stroke registry data from 5 tertiary referral hospitals in Australia and Canada from January 2011 to April 2022. Patients were aged 1 month to younger than 18 years with acute LVO stroke. Pooled data identified 31 thrombectomy patients and 46 control patients. Five patients undergoing thrombectomy with basilar artery occlusion were excluded due to insufficient controls. Using a hierarchal matching system (site of occlusion, age group, side of occlusion, and sex), deidentified consensus matching of patients and controls was undertaken while blinded to clinical outcome. Data were analyzed from July to November 2022.ExposureIn the case cohort, mechanical thrombectomy was undertaken for management of acute LVO stroke. The control cohort received medical treatment only.Main Outcomes and MeasuresThe primary outcome was the functional clinical status 3 months following stroke, measured by the pediatric modified Rankin Scale (mRS). Clinical outcomes were compared between groups using ordinal regression analysis.ResultsOf 52 included patients, 31 (60%) were male, and the mean (SD) age was 10.3 (4.4) years. Matching was achieved for 26 children undergoing thrombectomy with 26 controls. There was no significant difference between groups for site or side of occlusion, age, sex, etiology, thrombolysis status, baseline Alberta Stroke Programme Early CT Score, or time since last seen well to presentation. Patients undergoing thrombectomy had superior clinical outcomes than control patients at 3 months on the pediatric mRS (odds ratio, 3.76; 95% CI, 1.32-10.67; P = .01). These superior outcomes were maintained at final follow-up (odds ratio, 3.65; 95% CI, 1.25-10.68; P = .02).Conclusions and RelevanceIn the absence of a randomized clinical trial, this case-control study demonstrates better clinical outcomes with thrombectomy than medical management alone for pediatric patients aged 2 to 18 years with anterior circulation LVO stroke.

WITHDRAWN: Eligibility for thrombolysis and outcome in pediatric acute ischemic stroke

“…Observational studies suggest improved outcome in children treated with MT for large vessel occlusion (LVO) of the anterior and posterior circulations. [7][8][9] Efficacy of thrombolysis for pediatric AIS is even less well documented. Early attempts to offer thrombolysis were often compromised by delay and complications.…”

Predictors of the unfavorable outcomes in acute ischemic stroke patients treated with alteplase, a multi-center randomized trial

“…We found that mechanical thrombectomy was not a predictor of outcomes in AIS patients treated with alteplase; our findings disagreed with the findings of Bhatia and colleagues., 2023 who found that mechanical thrombectomy resulted in better clinical outcomes than conservative management for acute large vessel occlusion stroke 38 and this could be explained by disparities in the study population as Bhatia included only patients aged 2–years old.…”

Stroke in Children: Key Advances in the Field and the Next 20 Years

“…A recent case-control study found that outcomes were better in carefully selected children 2 to 18 years of age treated with mechanical thrombectomy for large vessel occlusion. 15 Thrombolysis remains an ongoing challenge in children with acute stroke; a prior pediatric safety and dose-finding trial of alteplase for stroke (TIPS [Thrombolysis in Pediatric Stroke]) closed due to low enrollment. 16 With increased pediatric stroke awareness, further studies seem feasible, but the adult stroke community's ongoing transition to the thrombolytic tenecteplase is complex for those who treat children given that pediatric pharmacokinetic data and dosing guidance are lacking.…”