Clinical Diffusion Mismatch to Select Pediatric Patients for Embolectomy 6 to 24 Hours After Stroke

Sporns, Peter; Psychogios, Marios‐Nikos; Sträeter, Ronald; Hanning, Uta; Minnerup, Jens; Chapot, René; Henkes, Hans; Henkes, Elina; Grams, Astrid; Dorn, Franziska; Nikoubashman, Omid; Wiesmann, Martin; Bier, Georg; Weber, W.; Broocks, Gabriel; Fiehler, Jens; Kaiser, Daniel; Yılmaz, Ümüt; Morotti, Andrea; Marik, Wolfgang; Nolz, Richard; Jensen‐Kondering, Ulf; Braun, Michael; Schob, Stefan; Beuing, Oliver; Goetz, Friedrich; Trenkler, Johannes; Turowski, Bernd; Möhlenbruch, Markus; Wendl, Christina; Schramm, Peter; Musolino, Patricia L.; Lee, Sarah; Schlamann, Marc; Radbruch, Alexander; Karch, André; Rübsamen, Nicole; Wildgruber, Moritz; Kemmling, André

doi:10.1212/wnl.0000000000011107

Cited by 26 publications

(18 citation statements)

References 18 publications

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“…The outcome in this case report is in line with the findings of a secondary analysis of the Save ChildS Study that included 20 patients aged <18 who had thrombectomy between 6 and 24 h after stroke onset based on mismatch between clinical deficit and infarct (6). In the cited study by Sporns et al, the authors reported a higher proportion of good outcomes as compared to the DAWN and DEFUSE3 studies, and a similar proportion of patients with good outcome in the group treated > 6 h as compared to the group treated < 6 h (6).…”

Section: Discussionsupporting

confidence: 73%

“…As for delay, two randomized trials in adults (DAWN and DEFUSE 3) demonstrated that the delay from stroke onset to thrombectomy can be extended beyond the usual 6-h window in patients who present a mismatch between the severity of the clinical deficit and the infarct volume, or between the infarct volume and the perfusion deficit (4,5). Also, a secondary analysis of the Save Child study, which focused on thrombectomy performed between 6 and 24 h based on the presence of a mismatch between clinical deficit and infarct in 20 patients aged <18, revealed a good functional outcome in these patients (6).…”

Section: Introductionmentioning

confidence: 99%

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Case Report: Late Successful Thrombectomy for Ischemic Stroke in a 2-Year-Old Child

et al. 2021

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Despite extensive evidence of benefit of thrombectomy in adult ischemic stroke due to large-vessel occlusion in the 6-h window, its role remains uncertain in very young children. We describe hereafter the case of a 2-year-old female child who had a successful thrombectomy 9 h after stroke onset. The patient presented with right hemiplegia, central facial palsy, a normal level of consciousness, and speech difficulties. The PedNIHS score was 11. CT scan without contrast injection displayed spontaneous hyperdensity of the middle cerebral artery (MCA), with only limited early signs of ischemia (ASPECTS 8). CT angiography demonstrated occlusion of the proximal MCA with good collaterals. Thrombectomy was realized. Complete recanalization (TICI 3) was obtained under general anesthesia after two passes of a stent retriever. Time from symptoms onset to full recanalization was 9 h. The acute ischemic stroke was caused by embolic thrombus from a congenital heart disease. Clinical recovery was complete. Three months after the thrombectomy, the young patient was doing well without any neurological sequelae (PedNIHSS 0; modified Rankin Scale: 0). This case report is an example of a decision-making process to perform thrombectomy in a very young child, which included cardio-embolic etiology as a parameter that potentially might have participated to the successful outcome of the therapeutic procedure.

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Section: Discussionsupporting

confidence: 73%

Section: Introductionmentioning

confidence: 99%

Case Report: Late Successful Thrombectomy for Ischemic Stroke in a 2-Year-Old Child

et al. 2021

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“…For mechanical thrombectomy (MT) in adults, several randomized clinical trials published in 2015 have shown the efficacy and safety of endovascular recanalization for large vessel occlusions (LVOs) with large effect size (8). In children, after several case series (9, 10), the retrospective Save ChildS Study recently provided the first systematic evidence for the safety of MT in children (11)(12)(13). In this study, the rate of recanalization and adverse events was comparable to large randomized controlled trials in adults, and neurological outcomes of the children were generally favorable.…”

Section: Introductionmentioning

confidence: 99%

A Prospective Multicenter Registry on Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke (Save ChildS Pro)

et al. 2021

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Rationale: Early evidence for the benefit of mechanical thrombectomy (MT) in pediatric patients with intracranial large vessel occlusion has been shown in previous retrospective cohorts. Higher-level evidence is needed to overcome the limitations of these studies such as the lack of a control group and the retrospective design. Randomized trials will very likely not be feasible, and several open questions remain, for example, the impact of arteriopathic etiologies or a possible lower age limit for MT. Save ChildS Pro therefore aims to demonstrate the safety and effectiveness of MT in pediatric patients compared to the best medical management and intravenous thrombolysis.Design: Save ChildS Pro is designed as a worldwide multicenter prospective registry comparing the safety and effectiveness of MT to the best medical care alone in the treatment of pediatric arterial ischemic stroke (AIS). It will include pediatric patients (<18 years) with symptomatic acute intracranial arterial occlusion who underwent either MT or best medical treatment including intravenous thrombolysis.Outcomes: The primary endpoint of Save ChildS Pro is the modified Rankin Scale score at 90 days post-stroke. Secondary endpoints will comprise the decrease of the Pediatric National Institutes of Health Stroke Scale score from admission to discharge and rate of complications.Discussion: Save ChildS Pro aims to provide high-level evidence for MT for pediatric patients with AIS, thereby improving functional outcome and quality of life and reducing the individual, societal, and economic burden of death and disability resulting from pediatric stroke.Clinical Trial Registration: Save ChildS Pro is registered at the German Clinical Trials Registry (DRKS; identifier: DRKS00018960).

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“… 63 – 67 However, a secondary analysis of the Save ChildS study has recently shown that thrombectomy in an extended time window of up to 24 h after onset of symptoms was safe and neurological outcomes were generally good, if patients were selected by a mismatch between clinical deficit and infarct. 68 The 2019 AHA guidelines were written before this evidence became available. 69 We therefore recommend to perform EVT in pediatric patients with LVO even in the extended time window beyond 6 h after symptom onset.…”

Section: Borderline Indications For Evtmentioning

confidence: 99%

Expanding indications for endovascular thrombectomy-how to leave no patient behind

Sporns

Fiehler

Ospel

et al. 2021

Ther Adv Neurol Disord

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Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.

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Clinical Diffusion Mismatch to Select Pediatric Patients for Embolectomy 6 to 24 Hours After Stroke

Cited by 26 publications

References 18 publications

Case Report: Late Successful Thrombectomy for Ischemic Stroke in a 2-Year-Old Child

Case Report: Late Successful Thrombectomy for Ischemic Stroke in a 2-Year-Old Child

A Prospective Multicenter Registry on Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke (Save ChildS Pro)

Expanding indications for endovascular thrombectomy-how to leave no patient behind

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