Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature

Abstract

Introduction Mechanical thrombectomy is standard treatment for large vessel occlusion (LVO) in adults. There are no randomized controlled trials for the pediatric population. We report our single-center experience with thrombectomy of LVO in a series of pediatric patients, and perform a review of the literature. Methods Retrospective review of consecutive pediatric thrombectomy cases between 2011 and 2018. Demographic variables, imaging data, technical aspects and clinical outcome were recorded. Results In a period of 7 years, 7 children were treated for LVO at our center. Median age was 13 (2–17), and median Ped-NIHSS was 15 (3–24), and the median ASPECTS was 8 (2–10). Five patients had cardiac disease, and 2 of them were under external cardiac assistance. Median time from onset of symptoms to beginning of treatment was 7h06m (2h58m–21h38m). Five patients had middle cerebral artery occlusions. Thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and combined technique in 1 patient. Six patients had good recanalization (TICI 2 b/3). There were no immediate periprocedural complications. At 3 months, 4 patients (57%) were independent (mRS score <3). Two patients died, one after haemorrhagic transformation of an extensive MCA infarct, and one due to extensive brainstem ischemia in the setting of varicella vasculitis. Discussion Selected pediatric patients with LVO may be treated with mechanical thrombectomy safely. In patients under external cardiac assistance and under anticoagulation, thrombectomy is the only alternative for treatment of LVO. A multidisciplinary approach in specialized pediatric stroke centers with trained neurointerventionalists are essential for good results.

Pediatric Stroke: Overview and Recent Updates

“…Similar outcomes like those seen by Satti et al are also echoed by subsequent systematic reviews and metaanalyses conducted by Bhatia et al and Fragata et al These systematic reviews and meta-analyses investigated the efficacy of mechanical thrombectomy for pediatric ischemic stroke due to large vessel occlusion [48,49]. The former study found that mechanical thrombectomy resulted in good long-term neurological outcomes (mRS scores between 0-2) in 87 out of 96 cases, good short-term outcomes (reduction in NIHSS by ≥ 8 points) in 55 out of 79 cases, and successful recanalization (modified Treatment in Cerebral Ischemia, mTICI, 2b/3) in 86 out of 98 cases [48].…”

“…Death occurred in two patients and symptomatic intracranial hemorrhage in one patient [48]. The latter study by Fragata et al reported seven cases over a period of seven years, in which five patients had cardiac disease, two of which were under external cardiac assistance, with a median time from onset of symptoms to treatment being approximately 7 hours [49]. Mechanical thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and a combined technique in one patient [49].…”

“…The latter study by Fragata et al reported seven cases over a period of seven years, in which five patients had cardiac disease, two of which were under external cardiac assistance, with a median time from onset of symptoms to treatment being approximately 7 hours [49]. Mechanical thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and a combined technique in one patient [49]. While six patients had good recanalization, two patients died, one after hemorrhagic transformation of a middle cerebral artery infarct, and the other due to extensive brainstem ischemia caused by varicella vasculitis [49].…”

“…Mechanical thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and a combined technique in one patient [49]. While six patients had good recanalization, two patients died, one after hemorrhagic transformation of a middle cerebral artery infarct, and the other due to extensive brainstem ischemia caused by varicella vasculitis [49]. In a slightly larger retrospective study, which included nineteen patients who underwent endovascular thrombectomy between 2008 and 2017 with an average age of 10.9 years and a NIHSS score of 13.9, a transfemoral approach utilizing stent retrievers and aspiration resulted in successful revascularization in 89.5% of patients with an average of 2.2 passes and a recanalization time of 48.7 minutes [50].…”

Endovascular Treatment of Acute Ischemic Stroke in Patients Younger than 18 Years

“…30 In contrast, Fragata et al noticed improvements in only 57% of the subjects. 31 In the study by Sun et al, of 11 children aged below 5 years, favorable outcomes were achieved in 64% of the patients. 32 The reasons for these observations could be the time lag in the initiation of treatment and the relatively younger age of the participants.…”