Clinically successful late recanalization of basilar artery occlusion in childhood: What are the odds?

Grigoriadis, Savvas; Gomori, John M.; Grigoriadis, Nikolaos; Cohen, José E.

doi:10.1016/j.jns.2007.03.028

Cited by 56 publications

(43 citation statements)

References 21 publications

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“…Yet, the author and his colleagues have anecdotal cases treated beyond 6 hours who had excellent clinical outcomes. 7,8,13,14 This current study suggests that in select patients with AIS with potentially salvageable brain tissue defined by CT perfusion (anterior circulation) or clinical-MRI mismatch (posterior circulation), IAT beyond 6 hours is feasible and safe with no increase in the risk of ICH or death. Moreover, this approach may be as effective as Ͻ6-hour IAT.…”

Section: Discussionmentioning

confidence: 69%

“…Esta aparente dependencia temporal ha sido uno de los principios fundamentales en la neurología del ictus. Sin embargo, el autor y sus colegas tienen experiencia de casos testimoniales tratados después de las 6 horas que han presentado unos resultados clínicos excelentes 7,8,13,14 . El presente estudio sugiere que, en pacientes con IIA seleccionados que tienen un tejido cerebral que puede ser salvado, según lo definido por la TC de perfusión (circulación anterior) o el mismatch clínico-RM (circulación posterior), el TIA aplicado después de las 6 horas es viable y seguro, y no comporta un aumento del riesgo de HIC o muerte.…”

Section: Discussionunclassified

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Endovascular Treatment of Acute Ischemic Stroke May Be Safely Performed With No Time Window Limit in Appropriately Selected Patients

Aböu-Chebl

2010

Stroke

111

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Background and Purpose-The traditional time window for acute ischemic stroke intra-arterial therapy (IAT) is Ͻ6 hours, which is based on pharmacological thrombolysis without penumbral imaging. This study was conducted to determine the safety of patient selection for IAT based on perfusion mismatch rather than time. Methods-A cohort of consecutive patients treated with IAT was identified by database review. Patients were selected for IAT based on the presence of perfusion mismatch using CT perfusion or MRI regardless of stroke duration. Thrombolytics were minimized after 6 hours in favor of mechanical embolectomy or angioplastyϮstenting. Outcomes (National Institutes of Health Stroke Scale, modified Rankin Scale) were assessed by independent examiners. A multivariate analysis was performed to compare those treated Ͻ6 hours (early) with those treated Ͼ6 hours (late). Results-Fifty-five patients (mean National Institutes of Health Stroke Scaleϭ19.7Ϯ5.7) were treated, 34 early and 21 late, with mean time-to-intervention of 3.4Ϯ1.6 hours and 18.6Ϯ16.0 hours, respectively. Thrombolysis In Myocardial Ischemia 2 or 3 recanalization was achieved in 82.8% early and 85.7% late patients (Pϭ1.0). Intracerebral hemorrhage occurred in 25.5% overall, but symptomatic intracerebral hemorrhage occurred in 8.8% of the early and 9.5% of the late patients (Pϭ1.0). Key Words: acute Ⅲ endovascular therapy Ⅲ perfusion imaging Ⅲ reperfusion Ⅲ stroke Ⅲ thrombolytic therapy T raditionally, patients with acute ischemic stroke (AIS) have not been treated with intra-arterial revascularization therapy (IAT) beyond 6 hours due to the perceived lack of benefit and increased risk of intracerebral hemorrhage (ICH). This concept is based on anecdotal experience with pharmacological thrombolysis and few randomized clinical trial data. 1 With modern imaging studies that assess the ischemic penumbra and the availability of mechanical devices for clot removal, it may be possible to treat patients beyond the 6-hour treatment window without increasing the risk of ICH. 2 The theoretical justification for this approach is that by limiting recanalization to those patients with minimal or small completed infarcts and large areas of perfusion mismatch, neuronal function may be spared without increasing the ICH risk, whereas revascularization of mostly infarcted tissue does not result in significant neuronal recovery and increases the risk of ICH because of associated endothelial, vascular and blood-brain barrier injury. Furthermore, pharmacological agents, particularly fibrinolytics, may have an increased propensity to cause ICH. 1,3-6 A few case series have reported treatment beyond the 6-hour window suggesting it may be feasible to treat patients presenting late. 7,8 Due to the significant number of patients with AIS presenting outside the 6-hour time window at the author's institution, an IAT protocol was developed using primarily CT, CT angiography, and CT perfusion imaging to select patients regardless of the time window. This retrospective study was c...

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Section: Discussionmentioning

confidence: 69%

Section: Discussionunclassified

Endovascular Treatment of Acute Ischemic Stroke May Be Safely Performed With No Time Window Limit in Appropriately Selected Patients

Aböu-Chebl

2010

Stroke

111

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“…We found 17 case reports, including our own 2 patients, which described IVT with tPA in 6 (35%) children, 19 -24 IAT in 10 (59%) children, 3 with additional angioplasty, 10,[25][26][27][28][29][30] and mechanical thrombolysis alone for BA occlusion in one (6%) child. 31 No symptomatic ICH was reported, but 2 asymptomatic ICHs occurred.…”

Section: Discussionmentioning

confidence: 96%

“…The lethal outcome of the boy who presented with a T occlusion and showed no MCA recanalization after IAT is in line with the unfavorable outcome of adults with this type of vessel occlusion. 33 Eight children underwent IAT in 7 cases (additional balloon angioplasty, nϭ3) 10,[27][28][29][30] or intra-arterial clot retrieval followed by balloon angioplasty (nϭ1) 31 for BA occlusion. All children survived, 6 with no or minimal deficits (mRS 0 to 1), one with a mRS of 2, and one remained severely disabled (mRS 4) after a follow-up ranging between 1 and 12 months.…”

Section: Discussionmentioning

confidence: 99%

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Thrombolysis in Childhood Stroke

Arnold

Steinlin

Baumann

et al. 2009

Stroke

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Background and Purpose-No controlled, randomized trial has investigated whether intravenous, intra-arterial (IAT), or mechanical thrombolysis is beneficial in children with ischemic stroke. We report 2 children who underwent IAT for acute ischemic stroke and include them in a review about intravenous thrombolysis, IAT, and mechanical thrombolysis for childhood stroke. Methods-We searched in MEDLINE and EMBASE for studies that reported on treatment of childhood stroke with intravenous thrombolysis, IAT, or mechanical thrombolysis in the presence of occlusion of the basilar artery, sphenoidal, or insular middle cerebral artery. To be included in this review, the following findings had to be reported:(1) stroke severity at presentation; (2) cerebral imaging findings before thrombolysis; (3) time to treatment; (4) dose of the thrombolytic agent; (5) pre-and postinterventional angiographic findings in IAT; and (6) outcome assessed at hospital discharge or within 12 months after thrombolysis. Results-Adequate data were available in 17 children (including our 2 own cases) who underwent intravenous thrombolysis (nϭ6), IAT (nϭ10), or mechanical thrombolysis (nϭ1). No symptomatic intracranial hemorrhage occurred, but 2 asymptomatic intracranial hemorrhages were present. Sixteen children (94%) survived, and 12 (71%) had a good outcome (modified Rankin Scale score 0 or 1). Conclusions-The available data about thrombolysis in pediatric stroke are limited. They suggest that this treatment may be beneficial in children with ischemic stroke. Controlled, randomized trials are needed to determine whether thrombolysis is useful in childhood stroke.

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Incidence and Natural History of Pediatric Large Vessel Occlusion Stroke

et al. 2022

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IMPORTANCEThe incidence and natural history of large vessel occlusion (LVO) stroke in children is largely unknown. These knowledge gaps limit the uptake of reperfusion therapies and reduce the efficiency of pediatric acute stroke pathways.OBJECTIVE To determine the incidence and natural history of pediatric LVO stroke. DESIGN, SETTING, AND PARTICIPANTSThis retrospective population-based cohort study was conducted between January 2010 and December 2019, with a mean (SD) follow-up of 37.0 (28.8) months. Admissions from all pediatric hospitals in the state of New South Wales, Australia, with a final diagnosis of arterial ischemic stroke (AIS) in patients 1 month to younger than 17 years were included. A total of 85 of 251 identified cases were excluded based on selection criteria. Data were analyzed from July 2020 to June 2021.EXPOSURES One-third of patients with LVO received mechanical thrombectomy with or without intravenous thrombolysis while the remainder were treated conservatively. MAIN OUTCOMES AND MEASURESThe primary outcome was the pediatric modified Rankin Scale (ped-mRS) score 3 months after stroke. Ordinal logistic regression was used to compare non-LVO, LVO without thrombectomy, and LVO with thrombectomy groups. RESULTSOf 161 included patients, 56 (34.8%) were female, and the mean (SD) age was 6.1 (5.4) years. A total of 166 AIS admissions were studied, and clinical follow-up was available for 164 of 166 admissions. LVO was present in 39 admissions (23.5%). The incidence of LVO stroke was 0.24 per 100 000 patients per year (95% CI, 0.13-0.35). Patients with LVO who did not receive thrombectomy (n = 26) had poor neurological outcomes, with 19 (73.1%) experiencing moderate to severe disability or death (ped-mRS score of 3 to 6) at 3 months (6 of 12 patients receiving thrombectomy [50.0%]; 25 of 38 patients with LVO [65.8%]). Patients with LVO without thrombectomy had significantly worse clinical outcomes than patients with non-LVO at 3 months (odds ratio, 3.64; 95% CI, 1.68-7.87; P = .001). Most patients with LVO presented within time windows suitable for thrombectomy (27 of 39 [69.2%] within 6 hours; 35 of 39 [89.7%] within 24 hours). CONCLUSIONS AND RELEVANCEIn this population-based cohort study, the natural history of pediatric patients with LVO stroke treated conservatively was poor, with most experiencing lifelong disability or death. Nearly 90% of pediatric patients with LVO presented within time windows suitable for thrombectomy.

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Clinically successful late recanalization of basilar artery occlusion in childhood: What are the odds?

Cited by 56 publications

References 21 publications

Endovascular Treatment of Acute Ischemic Stroke May Be Safely Performed With No Time Window Limit in Appropriately Selected Patients

Endovascular Treatment of Acute Ischemic Stroke May Be Safely Performed With No Time Window Limit in Appropriately Selected Patients

Thrombolysis in Childhood Stroke

Incidence and Natural History of Pediatric Large Vessel Occlusion Stroke

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