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Namikawa H, Ogata A, Furukawa T, Masuoka J, Abe T. Traumatic Vertebral Artery Dissection Without Cervical Spine Injury Treated by Mechanical Thrombectomy. Cureus 2024; 16:e60287. [PMID: 38872668 PMCID: PMC11175024 DOI: 10.7759/cureus.60287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
A 59-year-old female injured in a motor vehicle accident presented with progressively impaired consciousness, and emergent magnetic resonance imaging (MRI) revealed basilar artery occlusion (BAO). Mechanical thrombectomy (MT) was performed immediately and achieved complete recanalization. Contrast-enhanced MRI also indicated right vertebral artery dissection (VAD), and the patient was subsequently diagnosed with artery-to-artery embolism caused by traumatic VAD. Anticoagulation therapy was initiated postoperatively, and there was no VAD or BAO recurrence during the three-month follow-up. This is the first reported case of BAO caused by traumatic VAD in an adult without accompanying cervical vertebral fracture treated using MT.
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Affiliation(s)
| | - Atsushi Ogata
- Department of Neurosurgery, Saga University, Saga, JPN
| | | | - Jun Masuoka
- Department of Neurosurgery, Saga University, Saga, JPN
| | - Tatsuya Abe
- Department of Neurosurgery, Saga University, Saga, JPN
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Kim M, Subah G, Cooper J, Fortunato M, Nolan B, Bowers C, Prabhakaran K, Nuoman R, Amuluru K, Soldozy S, Das AS, Regenhardt RW, Izzy S, Gandhi C, Al-Mufti F. Neuroendovascular Surgery Applications in Craniocervical Trauma. Biomedicines 2023; 11:2409. [PMID: 37760850 PMCID: PMC10525707 DOI: 10.3390/biomedicines11092409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Michael Fortunato
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87108, USA
| | - Kartik Prabhakaran
- Department of Surgery, Division of Trauma and Acute Care Surgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children’s Hospital, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN 46032, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Alvin S. Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
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Rodríguez-López A, Gimeno I, Vila S, Seoane A, Ballenilla F, Ramos A, Hilario A, Núñez N, Camacho A, Simón R. Mechanical Thrombectomy for Acute Stroke in a 2-Month-Old Patient and Review of the Literature in Infancy. Neuropediatrics 2022; 53:376-380. [PMID: 35512844 DOI: 10.1055/a-1844-8780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Mechanical thrombectomy (MT) in pediatric stroke is supported by studies in adults, but there is controversy regarding younger patients. The main growth of intracranial vessels occurs up to 2 years when there can be more difficulties in MT.Description of the MT performed in a 2-month-old patient-the youngest infant published to date. We also review the literature on MT for stroke in infants.A 2-month-old patient presented with an awakening stroke secondary to an occlusion of the M1 segment of the left middle cerebral artery. A successful MT was performed with an aspiration device without clinically significant complications. An etiological study was completed, and neuroimaging showed focal cerebral arteriopathy. The 3-month outcome was excellent: the pediatric modified Rankin score was 0.Including this case, MT for acute stroke has been reported in only 10 infants. MT was successful in 90%, mostly using adult conventional stent retrievers. There were complications only in patients with mechanical circulatory support (MCS) devices; three patients died due to hemorrhagic transformation after MT and one patient died due to recurrent ischemic stroke.MT seems effective and safe in infants similarly to other pediatric ages. In children under 2 years of age, the presence of comorbidities requiring MCS devices is the main factor underlying poor prognosis.
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Affiliation(s)
| | - Isabel Gimeno
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sara Vila
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Andrea Seoane
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Federico Ballenilla
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Ramos
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amaya Hilario
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Noemí Núñez
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Camacho
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rogelio Simón
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Aburto-Murrieta Y, Méndez B, Marquez-Romero JM. Extended time window mechanical thrombectomy for pediatric acute ischemic stroke. J Cent Nerv Syst Dis 2022; 14:11795735221098140. [PMID: 35492739 PMCID: PMC9039450 DOI: 10.1177/11795735221098140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/15/2022] [Indexed: 11/17/2022] Open
Abstract
Endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) remains an off-label procedure seldom utilized in the pediatric population; this holds especially true for patients presenting outside the standard 6-hour time window. In this review we describe the published literature regarding usage of the extended time window EVT in pediatric stroke. We searched PubMed for all pediatric AIS cases and case series that included patients treated with extended time window EVT. We found data from 38 cases found in 27 publications (15 case reports and 12 case series). The median age was 10 years; 60.5% males. The median NIHSS before EVT was 13 with a median time-to-treatment of 11 hours. The posterior circulation was involved in 50.0%. Stent retrievers were used in 68.5%, and aspiration in 13.2%. Angiographic outcome TICI ≥2B was achieved in 84.2%, whereas TICI˂2B was reported in 10.6%. A favorable clinical outcome (NIHSS score ≤4, modified Rankin score ≤1, or Pediatric Stroke Outcome measure score ≤1) occurred in 84.2%. Eight cases that did not report the clinical outcome employing a standardized scale described mild to absent neurological residual deficits. This study found data that supports that extended window EVT produces high recanalization rates and good clinical outcomes in pediatric patients with AIS. Nevertheless, the source materials are indirect and contain substantial inconsistencies with an increased risk of bias that amount to low evidence strength.
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Affiliation(s)
- Yolanda Aburto-Murrieta
- Departamento de Terapia Endovascular Neurológica, Instituto Nacional de Neurología y Neurocirugía, “MVS”, CDMX, Mexico
| | - Beatriz Méndez
- Departamento de Terapia Endovascular Neurológica, Instituto Nacional de Neurología y Neurocirugía, “MVS”, CDMX, Mexico
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Stracke CP, Meyer L, Schwindt W, Ranft A, Straeter R. Case Report: Successful Mechanical Thrombectomy in a Newborn With Basilar Artery Occlusion. Front Neurol 2022; 12:790486. [PMID: 35273551 PMCID: PMC8901581 DOI: 10.3389/fneur.2021.790486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Neonatal stroke remains a rare condition that has not yet been assessed in the field of endovascular treatment. Case We present the first case report of a successful mechanical thrombectomy in a newborn with a basilar occlusion the treatment was 14 hours after birth. Complete reperfusion of the basilar artery was achieved after the two thrombectomy maneuvers with stent retrievers. Imaging follow-up proved patency of the target vessel and at day 30, the patient showed no neurologic deficits. Conclusions Mechanical thrombectomy appears to be technically feasible and can be an individual option in selected cases to treat stroke in neonates with proven persistent proximal cerebral artery occlusion.
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Affiliation(s)
- Christian Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfram Schwindt
- Section of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Alexander Ranft
- Department of Interventional Radiology and Neuroradiology, Klinikum Hochsauerland, Arnsberg, Germany
| | - Ronald Straeter
- Department of Pediatrics, University Hospital Muenster, Muenster, Germany
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Kondo R, Ishihara S, Uemiya N, Kakehi Y, Nakadate M, Singu T, Tsuzuki N, Tokushige K. Endovascular Treatment for Acute Ischaemic Stroke Caused by Vertebral Artery Dissection: A Report of Three Cases and Literature Review. NMC Case Rep J 2022; 8:817-825. [PMID: 35079554 PMCID: PMC8769423 DOI: 10.2176/nmccrj.cr.2021-0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/20/2021] [Indexed: 11/20/2022] Open
Abstract
Vertebrobasilar artery dissection is an uncommon cause of acute ischaemic stroke (AIS). Optimal endovascular management has not been established. This study aimed to share our experience with endovascular reperfusion therapy for vertebrobasilar artery occlusion due to vertebral artery dissection (VAD). We retrospectively reviewed 134 consecutive patients with AIS who received urgent endovascular reperfusion therapy between November 2017 and November 2019. Three patients diagnosed with VAD were investigated. The evaluation included mechanisms of vertebrobasilar artery occlusion due to VAD, variations in endovascular procedures, and functional outcomes. Dissections at the V3, V4 and extension of V3 to V4 segments were seen in one patient each. The mechanism of AIS was different in each patient: occlusion of the distal non-dissected artery due to an embolus from the dissection site (distal occlusion), haemodynamic collapse of the entire vertebrobasilar artery system due to the arterial dissection itself (local occlusion), or coexistence of distal occlusion and local occlusion (tandem occlusion). The endovascular reperfusion therapy was performed corresponding to the abovementioned mechanisms: mechanical thrombectomy for distal occlusion, stenting for local occlusion, and a combination of thrombectomy and stenting for tandem occlusion. In all three patients, effective recanalization and functional independence (modified Rankin Scale scores of 0–2 at 90 days after the onset) were achieved. Endovascular treatment corresponding to the individual mechanism of AIS may improve patient outcomes.
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Affiliation(s)
- Ryushi Kondo
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Shoichiro Ishihara
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Nahoko Uemiya
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Yoshiaki Kakehi
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Masashi Nakadate
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Takaomi Singu
- Department of Neuroendovascular Therapy, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Nobusuke Tsuzuki
- Department of Neurosurgery, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
| | - Kazuo Tokushige
- Department of Neurosurgery, Saitama Sekishinkai Hospital, Sayama, Saitama, Japan
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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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Fragata I, Morais T, Silva R, Nunes AP, Loureiro P, Diogo Martins J, Pamplona J, Carvalho R, Baptista M, Reis J. Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature. Interv Neuroradiol 2021; 27:16-24. [PMID: 32903115 PMCID: PMC7903541 DOI: 10.1177/1591019920958827] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/18/2020] [Indexed: 12/31/2022] Open
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.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Teresa Morais
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rita Silva
- Pediatric Neurology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Universitário Lisboa Central,
Lisboa, Portugal
| | - Petra Loureiro
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - José Diogo Martins
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Jaime Pamplona
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rui Carvalho
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Mariana Baptista
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - João Reis
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
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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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11
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Endovascular mechanical thrombectomy for acute stroke in young children. J Neurointerv Surg 2019; 11:554-558. [DOI: 10.1136/neurintsurg-2018-014540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 11/03/2022]
Abstract
BackgroundMechanical thrombectomy has emerged as a standard of care for acute stroke from large vessel occlusion in adults but remains controversial in children. Cerebral vessels are nearly adult size by 5 years of age but the technical feasibility of achieving recanalization in younger and smaller children with current endovascular tools remains unclear.ObjectiveTo systematically review the literature on mechanical thrombectomy for stroke in children less than 5 years of age.ResultsMechanical thrombectomy for acute stroke has been reported in 11 children under the age of 5 years (range 9 months to 4 years). The mean time from symptom onset to groin puncture was 12 hours (range 4–50 hours). Complete recanalization was achieved in 7/12 (58%) vessels attempted, and partial recanalization in 4/12 (33%). Two procedure related complications were reported, with small vessel size felt to be contributory to basilar vasospasm in one case. Favorable neurological outcomes were reported in 7 cases (64%).ConclusionsOur review of the literature demonstrates that mechanical thrombectomy for acute ischemic stroke may be feasible in carefully selected infants and young children less than 5 years of age using currently available devices. Efficacy in promoting better neurologic outcomes remains unproven, and other questions persist, including whether complications such as vasospasm occur more frequently in young children compared with adults. Further study is needed to determine the safety and efficacy of pediatric mechanical thrombectomy. These data suggest that young children should not be excluded from future studies or clinical treatment on the basis of age alone.
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12
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Ausman JI, Liebeskind DS, Gonzalez N, Saver J, Martin N, Villablanca JP, Vespa P, Duckwiler G, Jahan R, Niu T, Salamon N, Yoo B, Tateshima S, Buitrago Blanco MM, Starkman S. A review of the diagnosis and management of vertebral basilar (posterior) circulation disease. Surg Neurol Int 2018; 9:106. [PMID: 29930872 PMCID: PMC5991286 DOI: 10.4103/sni.sni_373_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/26/2017] [Indexed: 12/28/2022] Open
Abstract
We have reviewed the English literature published in the last 70 years on Diseases of the Vertebral Basilar Circulation, or Posterior Circulation Disease (PCD). We have found that errors have been made in the conduct and interpretation of these studies that have led to incorrect approaches to the management of PCD. Because of the difficulty in evaluating the PC, the management of PCD has been incorrectly applied from anterior circulation disease (ACD) experience to PCD. PCD is a common form of stroke affecting 20-40% patients with stroke. Yet, the evidence is strong that the Anterior Circulation (AC) and Posterior Circulations (PC) differ in their pathology, in their clinical presentations, in the rapidity of development of symptoms, in optimal imaging methods, and in available treatments. There appears to be two categories of patients who present with PCD. The first, acute basilar artery occlusion has a more rapid onset. The diagnosis must be made quickly and if imaging proves a diagnosis of Basilar Artery Occlusion (BAO), the treatment of choice is Interventional removal of the basilar artery thrombosis or embolus. The second category of PCD and the most commonly seen PCD disease process presents with non-specific symptoms and early warnings of PCD that now can be related to ischemic events in the entire PC vessels. These warning symptoms and signs occur much earlier than those in the AC. IA angiography is still the gold standard of diagnosis and is superior in definition to MR and CT angiography which are commonly used as a convenient screening imaging tool to evaluate PCD but are both inferior to IA angiography in definition for lesions below 3-4 mm. In at least two reported studies 7T MR angiography appears superior to other imaging modalities and will become the gold standard of imaging of PCD in the future. Medical treatments applied to the ACD have not been proven of value in specific forms of PCD. Interventional therapy was promising but of unproven value in Randomized Controlled Trials (RCT) except for the treatment of Basilar Artery Occlusion (BAO). Surgical revascularization has been proved to be highly successful in patients, who are refractory to medical therapy. These studies have been ignored by the scientific community basically because of an incorrect interpretation of the flawed EC-IC Bypass Trial in 1985 as applying to all stroke patients. Moreover, the EC-IC Bypass Study did not include PCD patients in their study population, but the study results were extrapolated to patients with PCD without any scientific basis. This experience led clinicians to an incorrect bias that surgical treatments are of no value in PCD. Thus, incorrectly, surgical treatments of PCD have not been considered among the therapeutic possibilities for PCD. QMRA is a new quantitative MR technique that measures specific blood flow in extra and intracranial vessels. QMRA has been used to select those patients who may benefit from medical, or interventional, or surgical treatment for PCD based on flow determinations with a high success rate. QMRA accurately predicts the flows in many large and small vessels in the PC and AC and clearly indicates that both circulations are intimately related. From medical and surgical studies, the longer one waits for surgical treatment the higher the risk of a poor outcome results. This observation becomes obvious when the rapidity of development of PCD is compared with ACD. Recent advances in endovascular therapy in the treatment of acute basilar thrombosis is a clear sign that early diagnosis and treatment of PCD will reduce the morbidity and mortality of these diseases. In this review it is evident that there are multiple medical and surgical treatments for PCD depending upon the location of the lesion(s) and the collateral circulation demonstrated. It is clear that the AC and PC have significant differences. With the exception of the large population studies from Oxford England, the reported studies on the management of PCD in the literature represent small selected subsets of the universe of PC diseases, the information from which is not generalizable to the universe of PCD patients. At this point in the history of PCD, there are not large enough databases of similar patients to provide a basis for valid randomized studies, with the exception of the surgical studies. Thus, a high index of suspicion of the early warning symptoms of PCD should lead to a rapid individual clinical assessment of patients selecting those with PCD. Medical, interventional, and/or surgical treatments should be chosen based on knowledge presented in this review. Recording the results in a national Registry on a continuing basis will provide the data that may help advance the management of PCD based on larger data bases of well documented patient information to guide the selection of future therapies for PCD treatments. It is also clear that the management of patients within the complex of diseases that comprise PCD should be performed in centers with expertise in the imaging, medical, interventional and surgical approaches to diseases of the PCD.
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Affiliation(s)
- James I. Ausman
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David S. Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Neurovascular Imaging Research Core, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Nestor Gonzalez
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jeffrey Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Neil Martin
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - J. Pablo Villablanca
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Paul Vespa
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gary Duckwiler
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Tianyi Niu
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Noriko Salamon
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Bryan Yoo
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Manuel M. Buitrago Blanco
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Sidney Starkman
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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13
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Sun LR, Pearl M, Bahouth MN, Carrasco M, Hoops K, Schuette J, Felling RJ. Mechanical Thrombectomy in an Infant With Acute Embolic Stroke. Pediatr Neurol 2018; 82:53-54. [PMID: 29622484 DOI: 10.1016/j.pediatrneurol.2018.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 02/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Monica Pearl
- The Johns Hopkins University School of Medicine, Department of Radiology, Division of Neurointerventional Radiology, Baltimore, Maryland
| | - Mona N Bahouth
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland
| | - Melisa Carrasco
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland
| | - Katherine Hoops
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Jennifer Schuette
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Ryan J Felling
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland
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