Endovascular therapy in children with acute ischemic stroke

Abstract

This review provides a summary of the currently available data pertaining to the interventional management of acute ischemic stroke in children. The literature is scarce and is lacking muchneeded prospective trials. No study in the literature on the well-established systemic or local thrombolysis trials has included children. Mechanical thrombectomy trials using clot retriever devices have also excluded patients younger than 18 years. The current review is limited to case series of interventional acute ischemic stroke therapy in children and the potential future of endovascular ischemic stroke therapy in this patient population. Recommendations in this review represent the opinion of the authors, based on review of the limited literature covering endovascular acute ischemic stroke therapy in children. Neurology ® 2012;79 (Suppl 1):S158-S164 GLOSSARY AIS ϭ acute ischemic stroke; IA ϭ intra-arterial; ICA ϭ internal carotid artery; MCA ϭ middle cerebral artery; TIPS ϭ Thrombolysis in Pediatric Stroke; tPA ϭ tissue plasminogen activator.The principal goal of acute endovascular therapy for arterial ischemic stroke (AIS) is prompt recanalization of the occluded vessel and restoration of blood flow to the ischemic brain. In adults with AIS, IV administration of tissue plasminogen activator (tPA) within 3 hours of symptom onset is associated with improved 3-month 1 and 1-year clinical outcomes 2 and is the only approved medical treatment for this condition.3 More recent studies demonstrate safety and suggest benefit from IV tPA up to 4.5 hours after symptom onset. 4 Patients presenting outside this therapeutic window or those with contraindications to IV tPA may benefit from intra-arterial (IA) pharmacological thrombolysis 5,6 or mechanical thrombolysis/thrombectomy with a variety of approved or investigational endovascular devices. [7][8][9] Following AIS, 3% to 6% of children will die, 25% will have recurrent stroke, and 70% will survive with life-long disability, 10 -12 resulting in decades of enormous personal and societal burden. There are no published clinical trials examining IV, IA, or endovascular mechanical thrombolytic strategies in children with AIS. However, despite age-related differences in cerebrovascular, coagulation, and fibrinolytic systems in children 13 and lack of established guidelines for thrombolytics in childhood AIS, 14 numerous cases have been reported in the literature. 13 The Thrombolysis in Pediatric Stroke (TIPS) trial will establish the safety and feasibility of IV tPA in children with AIS, 15 but there have been no such studies addressing the safety or efficacy of IA thrombolysis or endovascular therapies in the management of pediatric AIS, and no formal guidelines exist.The objectives of this report are to summarize the reported literature on the use of endovascular thrombolytic therapies in children with AIS and to address the potential role of endovascular techniques in the management of AIS in children.METHODS All reported cases of pediatric AIS in the English-language liter...

Acute Ischemic Stroke in Pediatric Patients

“…pediatric patients were excluded from these studies. When used in children, Ellis et al 10 found a recanalization (partial or complete) rate of 74% with a relatively high complication rate of 29%. The cause of the high complication rate was not discussed, but one can speculate that smaller pediatric vessels likely contribute.…”

“…most patients in this review received intra-arterial tpA alone, whereas a minority received mechanical thrombectomy. 10 Although mechanical thrombectomy is an option for children with significant neurological deficits and arterial occlusion, it remains experimental and should only be undertaken when families are aware of the risks.…”

Society of Vascular and Interventional Neurology (SVIN) Stroke Interventional Laboratory Consensus (SILC) Criteria: A 7M Management Approach to Developing a Stroke Interventional Laboratory in the Era of Stroke Thrombectomy for Large Vessel Occlusions

“…‘Ad hoc' catheter revascularization and other stroke interventions are increasingly performed immediately following the diagnostic angiographic component of the procedure. The scope of stroke interventional diagnostics in specialty populations such as pediatrics and pregnancy have already been established, but continue to grow and evolve with regard to therapeutic measures in stroke intervention [37,38]. …”

Metilen Tetrahidrofolat Reduktaz A1298C ve Plazminojen Aktivator Inhibitoru-1 4G/5G Polimorfizmli Cocuk Hastada Olümcül Akut Arteriyel Iskemik Inme

“…Gecikmiş tedavilerde (2-18 saat arası, ortalama 14 saat) bile %38 kısmi, %35' inde ise tam rekanalizasyon sağlanabildiği gösterilmiştir. Olguların %23,5' inde işlem sonrası komplikasyon olarak beyin içi kanama gelişmişse de bunların sadece %2.9'unun (bir olgu) semptomatik olduğu bildirilmektedir (13). Ülkemizde pediatrik endovasküler trombektomi deneyimi henüz erişkinlerde yapılan uygulamalarla kıyaslanabilecek ölçüde değildir.…”