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Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1213-1221. [PMID: 33719517 DOI: 10.1161/strokeaha.120.032009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke. METHODS This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes. RESULTS Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge. CONCLUSIONS Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Aurora (M.B.)
| | - Dwight Barry
- Clinical Analytics (D.B.), Seattle Children's Hospital
| | - Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine in St Louis (A.P.K.)
| | - Danial Hallam
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle (D.H.)
| | - Michael Abraham
- Departments of Neurology and Interventional Radiology, University of Kansas Medical Center (M.A.)
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2
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Panagopoulos D, Karydakis P, Markogiannakis G, Themistocleous M. Pediatric arterial ischemic stroke: Overview of the literature and of the most cited relevant articles. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Shweikeh F, Nuno M, Adamo M. Trends in endovascular interventions for pediatric ischemic stroke at the national level: data from 2000 to 2009. Childs Nerv Syst 2021; 37:161-166. [PMID: 32529548 DOI: 10.1007/s00381-020-04714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Present knowledge is limited with regard to endovascular and interventional management of pediatric acute ischemic stroke (AIS). The current practice of neurointerventions in this population was analyzed via a national database. METHODS The Kids' Inpatient Database for years 2000, 2003, 2006, and 2009 was examined for patients aged < 18 years discharged with a primary diagnosis of AIS and identified according to ICD-9 codes. Descriptive statistics were tabulated on each of the subcohorts. RESULTS There were 3467 patients identified; 920 (26.5%) underwent angiograms, 51 (1.5%) angiogram + thrombolysis, and 18 (0.5%) received angiogram + endovascular recanalization. The angiogram only subcohort was significantly younger compared with thrombolysis and endovascular procedure subcohorts (9.8 vs. 12.2 vs. 14.9 years, P < 0.001). Mortality was 4.3%, significantly lower for angiogram only than for thrombolysis (1.1% vs. 18.2%, P < 0.0001). Thrombolysis also had significantly higher hospital charges ($149,045 vs. $64,826, P < 0.0001). While not many differences in outcomes between angiogram only versus endovascular procedures, the latter had higher financial burden ($122,482 vs. $64,826, P < 0.0001). CONCLUSIONS This national study suggests that children receiving neurointerventions tend to be older (> 12 years) and heart and valvular defects are their most likely comorbidities. There was a lower mortality and fewer complications with endovascular procedures when compared with intravenous/intraarterial thrombolysis alone. Thrombolysis was also associated with more non-routine discharges and lengthier stay.
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Affiliation(s)
- Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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Adeeb N, Storey C, Vega AJ, Aslan A, Guthikonda B, Cuellar-Saenz H. Pediatric Middle Cerebral Artery Occlusion with Dissection Following a Trampoline Trauma. World Neurosurg 2020; 143:428-433. [PMID: 32750515 DOI: 10.1016/j.wneu.2020.07.175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Owing to the rarity of acute ischemic stroke in the pediatric population, evidence supporting the efficacy in children of the various treatments used in adults is scanty. This included mechanical thrombectomy for acute ischemic stroke. CASE DESCRIPTION we present the case of an 11-year-old female with acute left hemiparesis, numbness, and left facial droop occurring after tumbling on a trampoline. Computed tomography angiography revealed an 11-mm nonfilling defect in the right middle cerebral artery. She underwent thrombectomy approximately 8.5 hours after the onset of symptoms, and a Thrombolysis in Cerebral Infarction (TICI) scale score of 2b was achieved. She had an uneventful postoperative recovery. CONCLUSION Pediatric patients likely have more reserve and collateral flow and benefit from a longer therapeutic window following acute ischemic stroke.
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Affiliation(s)
- Nimer Adeeb
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA.
| | - Christopher Storey
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA
| | - Alexis J Vega
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA
| | - Asala Aslan
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA
| | - Hugo Cuellar-Saenz
- Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA
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Primary endovascular treatment for acute ischemic stroke in teenage patients: a short case series. Neuroradiology 2020; 62:851-860. [PMID: 32307558 DOI: 10.1007/s00234-020-02421-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/26/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE To analyze the safety and efficacy of primary endovascular treatment (EVT) for acute ischemic stroke (AIS) in patients younger than 18 years of age. METHODS Review of 4 patients < 18 years of age with AIS, prospectively enrolled in an electronic database registry for acute ischemic stroke patients who underwent thrombectomy at tertiary centers, from January 2011 to February 2017. Clinical and imaging data were analyzed. RESULTS All patients were female. Patients 1 to 4 were 14, 13, 16, and 13 years old, respectively. Patients 1 and 3 had left middle cerebral artery occlusion, patient 2 basilar occlusion, and patient 4 right tandem occlusion. Mean NIHSS score was 13 (7-19) on arrival and 4 (0-5) at 24 h. Patient 2 had Osler-Weber-Rendu disease and patient 4 a previously surgically repaired complete atrioventricular canal. All patients presented with clinical-radiological mismatch. CT/CTA was used in patients 1 and 4 and MRI/MRA in patients 2 and 3. Stent retriever was used in 3 patients (patients 1, 3, and 4) and direct aspiration first-pass technique in 1 (patient 2). All 4 procedures resulted in successful recanalization and 3-month functional independence. CONCLUSION Primary EVT is reported in patients 13 to 16 years of age with AIS due to large vessel occlusion and clinical-radiological mismatch. Procedures were safe and effective with prompt recanalization and good clinical outcome.
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Bhatia K, Kortman H, Blair C, Parker G, Brunacci D, Ang T, Worthington J, Muthusami P, Shoirah H, Mocco J, Krings T. Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series. J Neurosurg Pediatr 2019; 24:558-571. [PMID: 31398697 DOI: 10.3171/2019.5.peds19126] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge. METHODS Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3). RESULTS The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age. CONCLUSIONS Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.
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Affiliation(s)
- Kartik Bhatia
- 1Department of Neuroradiology, Toronto Western Hospital
- Departments of2Interventional Neuroradiology and
| | - Hans Kortman
- 1Department of Neuroradiology, Toronto Western Hospital
| | - Christopher Blair
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | | | - Timothy Ang
- Departments of2Interventional Neuroradiology and
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - John Worthington
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Prakash Muthusami
- 4Department of Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hazem Shoirah
- 5Department of Neurosurgery, Icahn School of Medicine at Mount Sinai; and
| | - J Mocco
- 6Department of Neurosurgery, The Mount Sinai Health System, New York, New York
| | - Timo Krings
- 1Department of Neuroradiology, Toronto Western Hospital
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Solitaire Stent Retriever Mechanical Thrombectomy in a 6-Month-Old Patient with Acute Occlusion of the Internal Carotid Artery Terminus: Case Report. World Neurosurg 2019; 126:631-637. [DOI: 10.1016/j.wneu.2019.03.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
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Hanser A, Sieverding L, Hauser T, Wiegand G, Hofbeck M. Stent‐retriever thrombectomy in the treatment of infants with acute thrombosis of the superior vena cava and innominate vein. Catheter Cardiovasc Interv 2019; 93:E357-E361. [DOI: 10.1002/ccd.28142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 01/28/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Anja Hanser
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | - Ludger Sieverding
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | | | - Gesa Wiegand
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
| | - Michael Hofbeck
- Department of Pediatric CardiologyUniversity Hospital Tuebingen Tuebingen Germany
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Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol 2018; 3:245-252. [PMID: 30637131 PMCID: PMC6312071 DOI: 10.1136/svn-2018-000181] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach. Case descriptions We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome. Discussion Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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10
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Primary versus secondary mechanical thrombectomy for anterior circulation stroke in children: An update. J Neuroradiol 2017; 45:102-107. [PMID: 29273535 DOI: 10.1016/j.neurad.2017.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 11/16/2017] [Accepted: 11/19/2017] [Indexed: 11/23/2022]
Abstract
This review of the literature on the use of mechanical thrombectomy (MT) in children with acute ischemic stroke from occlusion of the internal carotid artery and the proximal middle cerebral artery (MCA) compares the efficacy and safety of primary and secondary MT. We analyzed the data reported for 24 case reports from 20 relevant articles published up to 31 December 2016 and the data of a patient treated at our institution. Eighteen cases received primary MT and 7 received secondary MT. The proportions of complete MCA recanalization, small infarcts, and asymptomatic intracranial hemorrhage were similar in both MT groups (73% [11/15] vs. 67% [4/6], 58% [7/12] vs. 60% [3/5], and 15% [2/13] vs. 17% [1/6], respectively). The proportion of favorable neurological outcomes was higher for the primary MT group (69% [11/16] vs. 43% [3/7]). We found no substantial differences in efficacy and safety between primary and secondary MT for anterior circulation stroke in children.
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11
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Kulhari A, Dorn E, Pace J, Alambyan V, Chen S, Wu OC, Rizvi M, Hammond A, Ramos-Estebanez C. Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy? Front Neurol 2017; 8:634. [PMID: 29238322 PMCID: PMC5712569 DOI: 10.3389/fneur.2017.00634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/13/2017] [Indexed: 11/26/2022] Open
Abstract
Ischemic stroke is a rare condition to afflict the pediatric population. Congenital cardiomyopathy represents one of several possible etiologies in children. We report a 9-year-old boy who developed right middle cerebral artery stroke secondary to primary restrictive cardiomyopathy. In the absence of pediatric guidelines, the child met adult criteria for mechanical thrombectomy given the small core infarct and large penumbra. The literature suggests children may benefit from mechanical thrombectomy in carefully selected cases. Our patient exemplifies specific circumstances in which acute stroke therapy with thrombolysis and thrombectomy may be safe.
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Affiliation(s)
- Ashish Kulhari
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Elizabeth Dorn
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jonathan Pace
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Vilakshan Alambyan
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Stephanie Chen
- Department of Physiology, Case Western Reserve University, Cleveland, OH, United States
| | - Osmond C Wu
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Macym Rizvi
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
| | - Anthony Hammond
- Department of Emergency Medicine, University Hospitals, Cleveland, OH, United States
| | - Ciro Ramos-Estebanez
- Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.,Department of Neurological Surgery, Neurological Institute, University Hospitals, Cleveland, OH, United States
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12
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Cobb MIPH, Laarakker AS, Gonzalez LF, Smith TP, Hauck EF, Zomorodi AR. Endovascular Therapies for Acute Ischemic Stroke in Children. Stroke 2017; 48:2026-2030. [DOI: 10.1161/strokeaha.117.016887] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/23/2017] [Accepted: 04/27/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Mary In-Ping Huang Cobb
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
| | - Avra S. Laarakker
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
| | - L. Fernando Gonzalez
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
| | - Tony P. Smith
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
| | - Erik F. Hauck
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
| | - Ali R. Zomorodi
- From the Department of Neurosurgery (M.I.H.C., A.S.L., L.F.G., E.F.H., A.R.Z.) and Division of Interventional Radiology, Department of Radiology (T.P.S.), Duke University Hospitals, Durham, NC
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13
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Wilson JL, Eriksson CO, Williams CN. Endovascular Therapy in Pediatric Stroke: Utilization, Patient Characteristics, and Outcomes. Pediatr Neurol 2017; 69:87-92.e2. [PMID: 28233666 PMCID: PMC6394403 DOI: 10.1016/j.pediatrneurol.2017.01.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/16/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Despite strong evidence for endovascular therapy in adults with acute arterial ischemic stroke, limited data exist in children. We aimed to describe endovascular therapy utilization and explore outcomes in a national sample of pediatric arterial ischemic stroke. METHODS We queried the 2012 Kids' Inpatient Database for children aged greater than 28 days to 20 years with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for arterial ischemic stroke and evaluated groups based on the procedure code for endovascular therapy. Poor outcome was defined as need for tracheostomy or gastrostomy, discharge to rehabilitation facility, or death. Logistic regression evaluated the association between endovascular therapy and poor outcome, adjusted for age, disease severity (hemiplegia, critical care interventions, neurosurgical interventions), and comorbidities. RESULTS We identified 3184 pediatric discharges with a diagnosis code for arterial ischemic stroke. Thirty-eight (1%) had an endovascular therapy procedure code. Endovascular therapy patients were older (10.2 versus 4.5 years, P < 0.001) and more likely to have hemiplegia/paresis (relative risk [RR] 3.8, 95% confidence interval [CI] 2.0-7.4), aphasia (RR 5.3, 95% CI 2.8-10.1), and facial droop (RR 4.0, 95% CI 1.9-8.7). Endovascular therapy was not associated with critical care and neurosurgical interventions or intracranial hemorrhage. Length of hospitalization, mortality, and discharge disposition were similar between groups. In a multivariable model, endovascular therapy was not associated with poor outcome (adjusted odds ratio 1.7, 95%, CI 0.7-4.1). CONCLUSIONS In a national sample of children with a diagnosis of arterial ischemic stroke, endovascular therapy was infrequently utilized. Patients with a procedure code for endovascular therapy had significant stroke-related deficits, but outcomes were similar to those in children who did not receive endovascular therapy. Our data, in conjunction with evidence of benefit in adults, support consideration of endovascular therapy for select children with acute stroke.
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Affiliation(s)
- Jenny L. Wilson
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines St MC CDRC-P, Portland, OR 97239, Phone: (503) 494-5856, Fax: (503) 494-6868
| | - Carl O. Eriksson
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines St, CDRC-P, Portland, OR 97239
| | - Cydni N. Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines St, CDRC-P, Portland, OR 97239
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14
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Buompadre MC, Andres K, Slater LA, Mohseni-Bod H, Guerguerian AM, Branson H, Laughlin S, Armstrong D, Moharir M, deVeber G, Humpl T, Honjo O, Keshavjee S, Ichord R, Pereira V, Dlamini N. Thrombectomy for Acute Stroke in Childhood: A Case Report, Literature Review, and Recommendations. Pediatr Neurol 2017; 66:21-27. [PMID: 27769730 DOI: 10.1016/j.pediatrneurol.2016.09.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/08/2016] [Accepted: 09/07/2016] [Indexed: 01/08/2023]
Abstract
The updated American Heart Association/American Stroke Association guidelines include recommendation for thrombectomy in certain adult stroke cases. The safety and efficacy of thrombectomy in children are unknown. An 8-year-old girl experienced acute stroke symptoms on two occasions while therapeutically anticoagulated on Novalung. Computed tomography scans showed proximal vessel thrombi, which were retrieved using a Trevo device without hemorrhagic complications. Postprocedural assessment found respective decreases in the National Institutes of Health Stroke Scale score from 10 to 4 and 12 to 7. The indications for treatment and early benefits observed in our case are consistent with other pediatric thrombectomy cases reported. However, publication bias and the heterogeneity of reported cases prevent drawing conclusions about the safety and efficacy of thrombectomy in children. Anticipating that updates to adult stroke guidelines would likely incite stroke providers to consider thrombectomy in children, our institution developed guidelines for thrombectomy before the index patient. Establishing institutional guidelines before considering thrombectomy in children may optimize patient safety.
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Affiliation(s)
- Maria Celeste Buompadre
- Division of Neurology, Stroke Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathleen Andres
- Division of Neurology, Stroke Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lee-Anne Slater
- Department of Medical Imaging, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada; Department of Surgery, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Hadi Mohseni-Bod
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Helen Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suzanne Laughlin
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek Armstrong
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahendranath Moharir
- Division of Neurology, Stroke Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Division of Neurology, Stroke Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tilman Humpl
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Ichord
- Division of Neurology, The Children Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vitor Pereira
- Department of Medical Imaging, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada; Department of Surgery, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Stroke Program, The Hospital for Sick Children, Toronto, Ontario, Canada.
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15
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Weiner GM, Feroze RA, Agarwal N, Panczykowski DM, Ares WJ, Kooshkabadi A, Cummings DD, Carson V, Aghaebrahim A, Jankowitz BT. Successful Manual Aspiration Thrombectomy in a Pediatric Patient. Pediatr Neurol 2016; 61:107-13. [PMID: 27157625 DOI: 10.1016/j.pediatrneurol.2016.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/07/2016] [Accepted: 02/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents. PATIENT DESCRIPTION We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours. CONCLUSIONS Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke.
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Affiliation(s)
- Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rafey A Feroze
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ali Kooshkabadi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dana D Cummings
- Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vincent Carson
- Division of Child Neurology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amin Aghaebrahim
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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16
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Madaelil TP, Kansagra AP, Cross DT, Moran CJ, Derdeyn CP. Mechanical thrombectomy in pediatric acute ischemic stroke: Clinical outcomes and literature review. Interv Neuroradiol 2016; 22:426-31. [PMID: 26945589 DOI: 10.1177/1591019916637342] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/14/2016] [Indexed: 11/15/2022] Open
Abstract
There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke.
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Affiliation(s)
- Thomas P Madaelil
- Department of Neuroradiology, Mallinckrodt Institute of Radiology, USA
| | - Akash P Kansagra
- Department of Neuroradiology, Mallinckrodt Institute of Radiology, USA
| | - DeWitte T Cross
- Department of Neuroradiology, Mallinckrodt Institute of Radiology, USA Department of Neurological Surgery, Washington University School of Medicine, USA
| | - Christopher J Moran
- Department of Neuroradiology, Mallinckrodt Institute of Radiology, USA Department of Neurological Surgery, Washington University School of Medicine, USA
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, USA Department of Neurological Surgery, University of Iowa Hospitals and Clinics, USA Department of Neurology, University of Iowa Hospitals and Clinics, USA
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17
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See AP, Kochis MA, Khandelwal P, Orbach DB. Considerations in Applying a New Stent Retriever in Pediatric Endovascular Cerebral Thrombectomy for Acute Ischemic Stroke. Pediatr Neurosurg 2016; 51:263-8. [PMID: 27216798 DOI: 10.1159/000445902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/02/2016] [Indexed: 11/19/2022]
Abstract
Acute ischemic stroke (AIS) in children has been difficult to diagnose, treat and study, due to atypical clinical presentation, imaging challenges and the rarity of large-vessel embolic occlusion as the etiology of acute neurological change in children. With endovascular thrombectomy showing success in randomized trials of adult AIS, the technique is increasingly being extrapolated to pediatric stroke. However, there is little evidence regarding the safety or efficacy of applying in children these devices developed and tested in adults. There is concern about a vessel-to-device size mismatch that may result in a different complication and benefit profile than typically seen. We report on the successful application in pediatric stroke of a newer-generation, smaller stent retriever, designed to be delivered through relatively smaller and more navigable microcatheters than the prior generation of this device.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, Boston, Mass., USA
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18
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Vega RA, Chan JL, Anene-Maidoh TI, Grimes MM, Reavey-Cantwell JF. Mechanical thrombectomy for pediatric stroke arising from an atrial myxoma: case report. J Neurosurg Pediatr 2015; 15:301-5. [PMID: 25559920 DOI: 10.3171/2014.10.peds14292] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Children experiencing severe neurological deficit due to acute ischemic stroke may benefit from endovascular intervention. The authors describe the use of mechanical thrombectomy in the treatment of embolic occlusion secondary to an atrial myxoma in a pediatric patient. This case involved an 11-year-old boy with a history notable for Raynaud syndrome and a distal extremity rash who presented to the emergency department with dense hemiparesis secondary to thromboembolic occlusion of the M1 segment of the middle cerebral artery. Following mechanical thrombectomy, the patient's pediatric National Institutes of Health Stroke Scale score improved from a 16 to a 7. In the setting of acute pediatric stroke due to atrial myxoma emboli, mechanical thrombectomy may be a first-line therapy.
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19
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Ladner TR, He L, Jordan LC, Cooper C, Froehler MT, Mocco J. Mechanical thrombectomy for acute stroke in childhood: how much does restricted diffusion matter? BMJ Case Rep 2014; 2014:bcr-2014-011465. [PMID: 25391820 DOI: 10.1136/bcr-2014-011465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mechanical thrombectomy holds promise for children with large cerebral arterial occlusions, although there are few reports in this population. We report a case of retrievable stent-assisted mechanical thrombectomy in a 5-year-old with basilar artery occlusion, despite late presentation and extensive initial diffusion-weighted imaging (DWI) restriction. This resulted in successful Thrombolysis in Cerebral Infarction 2B reperfusion and excellent clinical outcome. At 6-week follow-up he was completely back to baseline with no residual deficits (pediatric stroke outcome measure=0, modified Rankin scale=0). At 3-month follow-up the patient has not had any recurrent stroke or concern for stroke-like symptoms. We review the literature on mechanical thrombectomy and DWI changes in acute stroke in early to middle childhood (<12 years old).
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Affiliation(s)
- Travis R Ladner
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Lucy He
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Lori C Jordan
- Division of Neurology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Calvin Cooper
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Michael T Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Mocco
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
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20
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Stidd DA, Lopes DK. Successful mechanical thrombectomy in a 2-year-old male through a 4-French guide catheter. Neurointervention 2014; 9:94-100. [PMID: 25426305 PMCID: PMC4239415 DOI: 10.5469/neuroint.2014.9.2.94] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/25/2014] [Indexed: 12/02/2022] Open
Abstract
A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.
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Affiliation(s)
- David A Stidd
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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