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Eastin TM, Dye JA, Pillai P, Lopez-Gonzalez MA, Huang L, Zhang JH, Boling WW. Delayed revascularization in acute ischemic stroke patients. Front Pharmacol 2023; 14:1124263. [PMID: 36843940 PMCID: PMC9945110 DOI: 10.3389/fphar.2023.1124263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Stroke shares a significant burden of global mortality and disability. A significant decline in the quality of life is attributed to the so-called post-stroke cognitive impairment including mild to severe cognitive alterations, dementia, and functional disability. Currently, only two clinical interventions including pharmacological and mechanical thrombolysis are advised for successful revascularization of the occluded vessel. However, their therapeutic effect is limited to the acute phase of stroke onset only. This often results in the exclusion of a significant number of patients who are unable to reach within the therapeutic window. Advances in neuroimaging technologies have allowed better assessment of salvageable penumbra and occluded vessel status. Improvement in diagnostic tools and the advent of intravascular interventional devices such as stent retrievers have expanded the potential revascularization window. Clinical studies have demonstrated positive outcomes of delayed revascularization beyond the recommended therapeutic window. This review will discuss the current understanding of ischemic stroke, the latest revascularization doctrine, and evidence from clinical studies regarding effective delayed revascularization in ischemic stroke.
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Affiliation(s)
- T. Marc Eastin
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Justin A. Dye
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Promod Pillai
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Miguel A. Lopez-Gonzalez
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lei Huang
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Pharmacology and Physiology, Loma Linda University, Loma Linda, CA, United States
| | - John H. Zhang
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Pharmacology and Physiology, Loma Linda University, Loma Linda, CA, United States,Department of Neurology, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Warren W. Boling
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,*Correspondence: Warren W. Boling,
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2
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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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3
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Camara R, Matei N, Zhang JH. Evolution of the stroke paradigm: A review of delayed recanalization. J Cereb Blood Flow Metab 2021; 41:945-957. [PMID: 33325765 PMCID: PMC8054720 DOI: 10.1177/0271678x20978861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow for reperfusion within 24 h after last known well time; however, many case studies report favorable outcomes beyond 24 h after symptom onset for both spontaneous and medically induced recanalization. Furthermore, modern imaging allows for identification of penumbra at extended time points, and reperfusion risk factors and complications are becoming better understood. Taken together, continued urgency exists to better understand the pathophysiologic mechanisms and ideal setting of delayed recanalization beyond 24 h after onset of ischemia.
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Affiliation(s)
- Richard Camara
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Nathanael Matei
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, USA.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA
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4
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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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5
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Matei N, Camara J, Zhang JH. The Next Step in the Treatment of Stroke. Front Neurol 2021; 11:582605. [PMID: 33551950 PMCID: PMC7862333 DOI: 10.3389/fneur.2020.582605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
Although many patients do not receive reperfusion therapy because of delayed presentation and/or severity and location of infarct, new reperfusion approaches are expanding the window of intervention. Novel application of neuroprotective agents in combination with the latest methods of reperfusion provide a path to improved stroke intervention outcomes. We examine why neuroprotective agents have failed to translate to the clinic and provide suggestions for new approaches. New developments in recanalization therapy in combination with therapeutics evaluated in parallel animal models of disease will allow for novel, intra-arterial deployment of therapeutic agents over a vastly expanded therapeutic time window and with greater likelihood success. Although the field of neuronal, endothelial, and glial protective therapies has seen numerous large trials, the application of therapies in the context of newly developed reperfusion strategies is still in its infancy. Given modern imaging developments, evaluation of the penumbra will likely play a larger role in the evolving management of stroke. Increasingly more patients will be screened with neuroimaging to identify patients with adequate collateral blood supply allowing for delayed rescue of the penumbra. These patients will be ideal candidates for therapies such as reperfusion dependent therapeutic agents that pair optimally with cutting-edge reperfusion techniques.
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Affiliation(s)
- Nathanael Matei
- Department of Ophthalmology, University of Southern California, Los Angeles, CA, United States
| | - Justin Camara
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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6
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Kang R, Gamdzyk M, Tang H, Luo Y, Lenahan C, Zhang JH. Delayed Recanalization-How Late Is Not Too Late? Transl Stroke Res 2020; 12:382-393. [PMID: 33215347 DOI: 10.1007/s12975-020-00877-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 01/01/2023]
Abstract
Stroke has become the second most prevalent cause of mortality in the world. Currently, the treatment of ischemic stroke is based on thrombolytic and thrombectomy therapy shortly after the ischemic event (≤ 4.5 h for thrombolytic strategies; ≤ 6 h for thrombectomy strategies). However, the majority of patients are unable to receive prompt treatment, particularly in undeveloped countries. Alternative solutions are lacking for those patients that miss the optimal window of opportunity for treatment. Recently, new developments in imaging techniques and intravascular interventional devices enable the expansion of the window of opportunity for treating stroke patients. Clinical studies have reported that delayed recanalization at 24 h, or even more than 1 month, was beneficial for some patients. However, the mechanisms of neuroprotection that underly the delayed recanalization in these ischemic stroke patients remain unclear. In this review, we will summarize the clinical studies of delayed recanalization, and organize them according to the duration of occlusion. Additionally, we will discuss the changing guidelines and possible mechanisms based on animal research, and attempt to draw conclusions and future perspectives.
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Affiliation(s)
- Ruiqing Kang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA.,Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Marcin Gamdzyk
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Hong Tang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Yujie Luo
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Cameron Lenahan
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA.,Burrell College of Osteopathic Medicine, Las Cruces, NM, 88003, USA
| | - John H Zhang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA. .,Department of Physiology and Pharmacology, Department of Anesthesiology, and Department of Neurosurgery, School of Medicine, Loma Linda University, 11041 Campus St, Risley Hall, Room 219, Loma Linda, CA, 92354, USA.
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7
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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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8
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Wilkinson DA, Pandey AS, Garton HJ, Savastano L, Griauzde J, Chaudhary N, Gemmete JJ. Republished: Late recanalization of basilar artery occlusion in a previously healthy 17-month-old child. J Neurointerv Surg 2018; 10:e17. [DOI: 10.1136/neurintsurg-2017-013277.rep] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/07/2017] [Accepted: 07/10/2017] [Indexed: 11/04/2022]
Abstract
Endovascular treatment of acute ischemic stroke in children is increasingly being reported, although the time window for intervention is unclear. We describe a previously healthy 17-month-old child who presented with vertebral artery thrombosis and cerebellar stroke requiring posterior fossa decompression. She later progressed to basilar artery thrombosis treated with mechanical thrombectomy 50 hours after clinical decline. At 3 month follow-up, the patient had a modified Rankin Scale score of 0.
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9
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Zhurkabayeva BD, Askarova AE, Berdina OD. A role of infection in the development of hemorrhagic stroke in children. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:31-37. [DOI: 10.17116/jnevro20181185231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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10
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Wilkinson DA, Pandey AS, Garton HJ, Savastano L, Griauzde J, Chaudhary N, Gemmete JJ. Late recanalization of basilar artery occlusion in a previously healthy 17-month-old child. BMJ Case Rep 2017; 2017:bcr-2017-013277. [PMID: 29030498 DOI: 10.1136/neurintsurg-2017-013277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Endovascular treatment of acute ischemic stroke in children is increasingly being reported, although the time window for intervention is unclear. We describe a previously healthy 17-month-old child who presented with vertebral artery thrombosis and cerebellar stroke requiring posterior fossa decompression. She later progressed to basilar artery thrombosis treated with mechanical thrombectomy 50 hours after clinical decline. At 3 month follow-up, the patient had a modified Rankin Scale score of 0.
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Affiliation(s)
- D Andrew Wilkinson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hugh J Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Luis Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Julius Griauzde
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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11
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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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12
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Abstract
Basilar artery occlusion has poor outcome in adults; little is known regarding outcomes in children. Whether intra-arterial treatments improve adult outcomes is controversial. Safety and efficacy of intra-arterial treatments in children are unknown. We report 5 cases of basilar artery occlusion and review published cases. We estimated National Institute of Health Stroke Scale (NIHSS) and modified Rankin Score (mRS) of published cases, compared scores between non-intra-arterial treatments and intra-arterial treatments groups, and examined the correlation between NIHSS and mRS. Of our cases, 4 had good outcomes and 1 died. Of 63 published cases, 45 had no intra-arterial treatments and 18 had intra-arterial treatments. In the non-intra-arterial treatments group 24 had good outcomes. In the intra-arterial treatments group 13 had good outcomes. There was strong correlation between the NIHSS and the mRS. Children with basilar artery occlusion have better outcomes than adults. Certain children with basilar artery occlusion may be treated conservatively. A registry for childhood basilar artery occlusion is urgently needed.
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Affiliation(s)
| | - Warren D. Lo
- Department of Pediatrics, Ohio State University, Columbus, OH, USA
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13
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Sainz de la Maza S, De Felipe A, Matute MC, Fandiño E, Méndez JC, Morillo P, Masjuan J. Acute ischemic stroke in a 12-year-old successfully treated with mechanical thrombectomy. J Child Neurol 2014; 29:269-73. [PMID: 24272519 DOI: 10.1177/0883073813509889] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report the case of a healthy 12-year-old girl with an acute ischemic stroke successfully treated with mechanical thrombectomy. The child was referred to our hospital 6 hours after sudden onset of severe headache and left hemiparesis. Cerebral angiography findings were consistent with right distal internal carotid artery occlusion in addition to ipsilateral middle cerebral artery occlusion. Subsequent mechanical thrombectomy with Solitaire AB device resulted in complete vessel recanalization. The patient experienced progressive neurologic improvement with good clinical recovery at the 3-month follow-up. To our knowledge, only 3 cases of primary mechanical thrombectomy in children have been previously reported in the literature. Safety and efficacy data for endovascular therapies in pediatric acute ischemic stroke are lacking. We propose mechanical thrombectomy as an option in children with significant neurologic deficits and proven arterial occlusion, especially when the therapeutic window for intravenous thrombolysis has been exceeded.
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Affiliation(s)
- Susana Sainz de la Maza
- 1Department of Neurology, Comprehensive Stroke Center, Hospital Universitario Ramón y Cajal, Madrid, Spain
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14
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Abstract
Stroke is a rare but increasingly recognized disorder in children. Current therapies for arterial ischemic stroke include thrombolytic, antithrombotic and antiplatelet agents, blood transfusion and surgery. Adult studies, pediatric case studies and expert opinion form the basis for these treatment strategies. Thrombolytic agents are increasingly used but, as in adults, the majority of arterial ischemic strokes in children are treated with antiplatelet and antithrombotic agents. Sickle-cell patients, a distinct subset of the pediatric stroke population, are treated primarily with transfusion therapy. Pediatric arterial ischemic stroke studies are needed to determine the most appropriate course of treatment. An international study is currently in progress to formally study the incidence, risk factors, treatment strategies and outcomes of stroke in children.
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Affiliation(s)
- Jessica Carpenter
- Children's National Medical Center, Department of Neurology, Washington, DC 20010, USA.
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15
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Fink J, Sonnenborg L, Larsen LL, Born AP, Holtmannspötter M, Kondziella D. Basilar Artery Thrombosis in a Child Treated With Intravenous Tissue Plasminogen Activator and Endovascular Mechanical Thrombectomy. J Child Neurol 2013; 28:1521-1526. [PMID: 23034976 DOI: 10.1177/0883073812460334] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basilar artery occlusion in children is rare. It has a high mortality and morbidity if recanalization is not achieved before extensive brainstem infarction has occurred. An 11-year-old boy presented with a clinical and radiological "top-of-the-basilar" syndrome. Intravenous tissue plasminogen activator was administered, and the patient was immediately referred to the regional stroke center. Subsequent mechanical thrombectomy using a Solitaire stent (Solitaire FR stent; ev3, Irvine, CA, USA) resulted in clot removal and recanalization of the basilar artery 4 hours after stroke onset. The patient made a full clinical recovery. To the authors' knowledge this is the first report on basilar artery occlusion in a child treated with "bridging" therapy, the combination of intravenous thrombolysis and endovascular thrombectomy. If the diagnosis can be made within the time window for intravenous thrombolysis (4.5 hours), the present case suggests that bridging therapy in pediatric basilar artery occlusion can be safe and effective.
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Affiliation(s)
- Jakob Fink
- 1Department of Radiology, Roskilde Hospital, Roskilde, Denmark
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16
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Titomanlio L, Zanin A, Sachs P, Khaled J, Elmaleh M, Blanc R, Piotin M. Pediatric ischemic stroke: acute management and areas of research. J Pediatr 2013; 162:227-35.e1. [PMID: 23153863 DOI: 10.1016/j.jpeds.2012.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/08/2012] [Accepted: 09/10/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Luigi Titomanlio
- Pediatric Emergency Department, APHP, Robert Debré Hospital, Paris Diderot University, Paris, France.
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Condie J, Shaibani A, Wainwright MS. Successful treatment of recurrent basilar artery occlusion with intra-arterial thrombolysis and vertebral artery coiling in a child. Neurocrit Care 2012; 16:158-62. [PMID: 21732156 DOI: 10.1007/s12028-011-9579-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Signs of brainstem ischemia in children may be subtle, and outcome following basilar artery occlusion is often poor. There currently are no guidelines in children regarding the best methods to diagnose and treat basilar artery occlusion. METHODS Case report and literature review. RESULTS We describe the presentation and management of recurrent basilar artery occlusion in a previously healthy 5-year-old boy with vertebral artery dissection. Treatment included emergent intra-arterial tPA and mechanical thrombolysis of basilar artery clot, followed by later coiling of the vertebral artery to prevent recurring episodes of basilar artery ischemia. CONCLUSION Management of brainstem stroke in children requires coordination of neurology, critical care, and interventional radiology services. Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children.
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Affiliation(s)
- John Condie
- Department of Pediatrics, Division of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60614-3394, USA
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Taneja SR, Hanna I, Holdgate A, Wenderoth J, Cordato DJ. Basilar artery occlusion in a 14-year old female successfully treated with acute intravascular intervention: case report and review of the literature. J Paediatr Child Health 2011; 47:408-14. [PMID: 21276116 DOI: 10.1111/j.1440-1754.2010.01974.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Basilar artery occlusion (BAO) is a rare cause of paediatric stroke that may result in severe neurological disability including a 'locked-in' state. Acute interventional therapy for paediatric BAO is limited to a small number of published case reports. Of 13 previously published cases that have undergone acute intravascular therapy, six made a full neurological recovery, six had residual deficits ranging from mild dysarthria and ataxia to vegetative state and one patient died. The time from symptom onset to intervention was ≥ 12 h in 77% (10/13). We reported a 14-year-old female patient presenting with altered sensorium that progressed to a 'locked-in' state due to idiopathic BAO who made a full clinical recovery after successful mechanical thrombectomy at 24 h following symptom onset. Acute neuro-interventional therapy for paediatric BAO can result in complete neurological recovery despite the presence of severe neurological deficits and a prolonged period of time from symptom onset to clinical diagnosis.
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Affiliation(s)
- Sanjeev R Taneja
- Department of Neurology, Liverpool Hospital, Liverpool, Sydney, New South Wales, Australia
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19
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Foster JR, Morrison G, Fraser DD. Diabetic ketoacidosis-associated stroke in children and youth. Stroke Res Treat 2011; 2011:219706. [PMID: 21423557 PMCID: PMC3056450 DOI: 10.4061/2011/219706] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 11/12/2010] [Accepted: 12/04/2010] [Indexed: 01/14/2023] Open
Abstract
Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency, either absolute or relative, resulting in hyperglycemia and ketonemia. Although possibly underappreciated, up to 10% of cases of intracerebral complications associated with an episode of DKA, and/or its treatment, in children and youth are due to hemorrhage or ischemic brain infarction. Systemic inflammation is present in DKA, with resultant vascular endothelial perturbation that may result in coagulopathy and increased hemorrhagic risk. Thrombotic risk during DKA is elevated by abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. DKA-associated cerebral edema may also predispose to ischemic injury and hemorrhage, though cases of stroke without concomitant cerebral edema have been identified. We review the current literature regarding the pathogenesis of stroke during an episode of DKA in children and youth.
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Affiliation(s)
- Jennifer Ruth Foster
- Critical Care Medicine and Paediatrics, University of Western Ontario, London, ON, Canada N6A 5W9
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20
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El-Hakam LM, Volpi J, Mawad M, Clark G. Angioplasty for acute stroke with pediatric moyamoya syndrome. J Child Neurol 2010; 25:1278-83. [PMID: 20505156 DOI: 10.1177/0883073809357471] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Moyamoya vasculopathy is a progressive, occlusive vasculopathy leading to ischemic and hemorrhagic strokes. No treatments are established to treat acute ischemic stroke with moyamoya vasculopathy. A 3-year-old girl with moyamoya syndrome developed acute left hemiplegia. Emergent angiography showed near-occlusion of the supraclinoid segment of the right internal carotid artery. Balloon angioplasty was performed within 6 hours of symptom onset, with significant improvement in the child's neurological symptoms. This is the youngest case of intracranial balloon angioplasty, and this article discusses the paucity of data regarding angioplasty and other forms of endovascular intervention in pediatric cerebrovascular disease and moyamoya vasculopathy. Further study is needed to determine the safety and efficacy of endovascular intervention in these diseases.
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Affiliation(s)
- Lisa Michael El-Hakam
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas 77030, USA.
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21
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Dashti SR, Park MS, Stiefel MF, McDougall CG, Albuquerque FC. Endovascular Recanalization of the Subacute to Chronically Occluded Basilar Artery. Neurosurgery 2010; 66:825-31; discussion 831-2. [DOI: 10.1227/01.neu.0000367611.78898.a3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
INTRODUCTION
Occlusion of the basilar artery (BA) has a poor prognosis. We evaluated technical considerations and complications associated with reopening subacute to chronically occluded BAs.
METHODS
Duration of BA occlusion before revascularization, symptoms and medical management before treatment, and postprocedural antiplatelet regimen and anticoagulation protocols of 9 patients were analyzed. All patients underwent endovascular low-volume balloon angioplasty followed by Wingspan stenting.
RESULTS
The median time between onset of symptoms and treatment was 5 days (range, 2 days to 3.5 years). The median time between documentation of BA occlusion by cerebral angiography or computed tomography angiography and treatment was 3 days (range, 1 day to 8 months). Recanalization was successful in 8 of the 9 patients. Immediately after the procedure, 4 patients were stable, 3 patients improved, and 2 patients were worse. Four patients had periprocedural complications. Four of the 9 patients died, 2 from periprocedural complications. The mean clinical duration of follow-up was 11 months. At latest follow-up, the modified Rankin Scale scores for the 5 surviving patients were 0, 0, 2, 2, and 3, respectively. During the follow-up period, 4 patients improved, 1 patient remained stable, and 1 patient died. The mean angiographic follow-up was 8.6 months. Two patients developed significant in-stent stenosis during this period.
CONCLUSION
With current endovascular techniques, recanalization of chronically occluded BAs is feasible. The procedure carries substantial risks and should be reserved for patients with medically refractory symptoms. Careful postprocedural medical management and radiographic follow-up are warranted to prevent in-stent restenosis.
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Affiliation(s)
- Shervin R. Dashti
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- Current Address: Norton Neuroscience Institute, Norton Hospital, Louisville, Kentucky
| | - Min S. Park
- Division of Neurosurgery, University of California at San Diego, San Diego, California
| | - Michael F. Stiefel
- Department of Neurosurgery and Division of Interventional Neuroradiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cameron G. McDougall
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C. Albuquerque
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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22
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23
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Bhatt A. Thrombolysis in Very Young Children. Stroke 2009; 40:e596; author reply e597. [DOI: 10.1161/strokeaha.109.547141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Archit Bhatt
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, Mich
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Arnold M, Steinlin M, Baumann A, Nedeltchev K, Remonda L, Moser SJ, Mono ML, Schroth G, Mattle HP, Baumgartner RW. Thrombolysis in Childhood Stroke. Stroke 2009; 40:801-7. [DOI: 10.1161/strokeaha.108.529560] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marcel Arnold
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Maja Steinlin
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Andreas Baumann
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Krassen Nedeltchev
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Luca Remonda
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Sonya Jourdan Moser
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Marie-Luise Mono
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Gerhard Schroth
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Heinrich P. Mattle
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
| | - Ralf W. Baumgartner
- From the Departments of Neurology (M.A., A.B., K.N., M.-L.M., H.P.M.), Pediatrics (M.S., S.J.M.), and Neuroradiology (L.R., G.S.), University Hospital of Berne, Inselspital, University of Berne, Berne, Switzerland; and the Department of Neurology (R.W.B.), University Hospital of Zurich, Zurich, Switzerland
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25
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Waje-Andreassen U, Thomassen L, Aarli Å, Kråkenes J, Norgård G, Russell D. Trombolytisk behandling ved arterielt hjerneinfarkt hos barn. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2219-22. [DOI: 10.4045/tidsskr.09.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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26
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Tsivgoulis G, Horton JA, Ness JM, Patterson D, Brethour M, Abanses JC, Alexandrov AV. Intravenous thrombolysis followed by intra-arterial thrombolysis and mechanical thrombectomy for the treatment of pediatric ischemic stroke. J Neurol Sci 2008; 275:151-3. [DOI: 10.1016/j.jns.2008.07.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2007] [Revised: 06/01/2008] [Accepted: 07/17/2008] [Indexed: 11/28/2022]
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Treatment of a Basilar Artery Occlusion with Intra-arterial Thrombolysis in a 3-year-old Girl. Neurocrit Care 2008; 9:357-60. [DOI: 10.1007/s12028-008-9086-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Grigoriadis S, Gomori JM, Grigoriadis N, Cohen JE. Clinically successful late recanalization of basilar artery occlusion in childhood: What are the odds? J Neurol Sci 2007; 260:256-60. [PMID: 17482211 DOI: 10.1016/j.jns.2007.03.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 03/25/2007] [Accepted: 03/29/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE Acute basilar artery occlusion is an infrequent but potentially fatal cause of stroke, both in adults and children. We present our experience with a 6-year-old child and we investigate the rationality for late treatment of acute basilar occlusion in children. METHODS We report the case of a 6-year-old boy with acute basilar artery occlusion presented with a full blown locked-in syndrome, admitted to the endovascular suite 44 h after the stroke onset, and we review all the reported cases of basilar artery occlusions presented with locked-in syndrome in children. RESULTS Six hours following admission the basilar artery was partially recanalized by intra-arterial thrombolysis combined with mechanical clot angioplasty. After 12 h, the patient was awake, oriented, his speech function was fully restored and he had only a mild right hemiparesis that recovered completely after a month. CONCLUSIONS To our knowledge, this is the first report of complete clinical recovery after delayed (50 h) endovascular recanalization of basilar artery in a child. Intra-arterial thrombolysis combined with cerebral angioplasty, can successfully restore the patency of the basilar artery and the neurologic deficit of children with acute basilar artery occlusion, even after a considerable delay.
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Affiliation(s)
- Savvas Grigoriadis
- Hadassah Stroke Center, Hadassah University Hospital, Jerusalem, Israel.
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31
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Abstract
Background and Purpose—
Few pediatric reports of thrombolysis exist. We sought to determine national rates of thrombolysis among pediatric ischemic stroke patients using a national database.
Methods—
Patients between the ages of 1 and 17 years, entered in the Nationwide Inpatient Sample between 2000 and 2003, with International Classification of Diseases codes for ischemic stroke were included in the study. Differences in mean age, gender distribution, ethnicity, secondary diagnoses, medical complications, associated procedure rates, modes of discharge, and hospital costs between pediatric stroke patients receiving and not receiving thrombolysis were estimated.
Results—
In the United States, between 2000 and 2003 an estimated 2904 children were admitted with ischemic stroke, of which 46 children (1.6%) received thrombolytic therapy. Children who received thrombolysis were on the average older (11 versus 9 years), more likely to be male (100% versus 53.8%), with significantly higher hospital costs ($81 800 versus $38 700). These children were also less likely to be discharged home with higher rates of death and dependency, although differences in clinical severity between the 2 groups was not known.
Conclusion—
Thrombolysis, though not indicated for patients <18 years of age, is currently being administered to children, with unclear benefit. Larger studies are needed to evaluate the safety and efficacy of this treatment for children.
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Affiliation(s)
- Nazli Janjua
- Long Island College Hospital, Department of Neurology, Brooklyn, NY 11201, USA.
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33
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Aleu A, Mellado P, Lichy C, Köhrmann M, Schellinger PD. Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke. Stroke 2007; 38:417-22. [PMID: 17185641 DOI: 10.1161/01.str.0000254504.71955.05] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Only 2% to 4% of patients with acute ischemic stroke receive thrombolytic therapy resulting from the current strict inclusion criteria among other issues. Safety of intravenous and intraarterial thrombolysis in off-label situations is controversially discussed. We sought to review the reports on such patients regarding intra- and extracranial hemorrhage. SUMMARY OF REVIEW A MEDLINE search for off-label uses of thrombolysis revealed reports on 273 patients treated with intraarterial or intravenous thrombolysis for ischemic stroke. Symptomatic intracranial hemorrhage occurred in 19 of 273 patients (6.95%) and extracranial hemorrhage in 17 of 273 (6.22%). CONCLUSIONS These data suggest that the overall bleeding risk in off-label thrombolysis may not be as high as presumed. However, the small number of patients in each group and the likely underreporting of worse outcomes preclude drawing any conclusion as to specific treatment recommendations. Selected patients might benefit, however, from thrombolysis in situations not currently considered in the inclusion criteria. To obtain a meaningful database, a registry for off-label thrombolysis should be created.
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Affiliation(s)
- Aitziber Aleu
- Department of Neurology, Neurointensive Care Unit, University of Heidelberg, Heidelberg, Germany.
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34
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Abstract
Evidence-based therapeutic interventions for pediatric ischemic cerebrovascular disease are beginning to emerge. The primary therapeutic target is usually the pathological prothrombotic disturbance that underlies the majority of pediatric stroke. A battle between anticoagulation and anti-platelet therapies continues to provide controversy and is the inspiration for upcoming randomized trials. Supportive care and neuroprotective strategies are an important consideration in children with stroke. Attempts to determine the safety of acute thrombolytic interventions are also underway. Finally, unique medical and surgical treatments for specific diseases leading to stroke in children continue to evolve. After briefly summarizing the epidemiology, pathophysiology, diagnosis, and outcomes of ischemic strokes in children, treatment approaches and alternatives will be reviewed in detail with emphasis placed on current areas of controversy and future directions for clinical research.
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Affiliation(s)
- Adam Kirton
- Children’s Stroke Program, Department of Pediatrics, Division of Neurology, Faculty of Medicine, University of Toronto, Hospital for Sick Children, M5G 1X8 Toronto, ON Canada
| | - Gabrielle deVeber
- Children’s Stroke Program, Department of Pediatrics, Division of Neurology, Faculty of Medicine, University of Toronto, Hospital for Sick Children, M5G 1X8 Toronto, ON Canada
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35
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Ho J, Mah JK, Hill MD, Pacaud D. Pediatric stroke associated with new onset type 1 diabetes mellitus: case reports and review of the literature. Pediatr Diabetes 2006; 7:116-21. [PMID: 16629718 DOI: 10.1111/j.1399-543x.2006.00151.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Neurological deterioration in children with diabetic ketoacidosis (DKA) is commonly caused by cerebral edema. However, stroke should also be suspected when focal neurological deficits are apparent, because children with hyperglycemia and DKA are prone to thrombosis. We report three cases of pediatric stroke associated with new onset type 1 diabetes mellitus (T1DM). The first case presented with sinovenous thrombosis, and the other two cases presented in DKA and had a late diagnosis of ischemic stroke following neurological deterioration. Our recent experiences and review of the literature emphasize the importance of early diagnosis, investigation, and treatment for patients that present with new onset T1DM and stroke.
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Affiliation(s)
- Josephine Ho
- Division of Endocrinology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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36
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Ho J, Pacaud D, Hill MD, Ross C, Hamiwka L, Mah JK. Diabetic ketoacidosis and pediatric stroke. CMAJ 2005; 172:327-8. [PMID: 15684112 PMCID: PMC545752 DOI: 10.1503/cmaj.1032013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Josephine Ho
- Division of Endocrinology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alta
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Abstract
PURPOSE OF THE REVIEW To summarize the current literature on central nervous system vasculitis in childhood because this condition remains a diagnostic and therapeutic challenge. RECENT FINDINGS Central nervous system vasculitis in childhood may be primary or secondary to a variety of conditions including infections, collagen vascular diseases, systemic vasculitides, and malignancies. Conditions that result in vasospasm or are associated with noninflammatory vasculopathies may mimic the features of central nervous system vasculitis. Recent studies have described the clinical spectrum of CNS vasculitis in childhood. The most common presenting features are headaches and focal neurologic deficits. The diagnosis of central nervous system vasculitis remains particularly difficult because the available investigative modalities have limited sensitivities and specificities. The most helpful diagnostic tests include cerebrospinal fluid analysis, MRI of the brain, and angiography. However, brain biopsy may be required to diagnose small vessel vasculitis. SUMMARY This review summarizes recent data on primary central nervous system vasculitis and some of the secondary CNS vasculitides in children. Awareness of the presenting clinical features of CNS vasculitis should lead to consideration of the diagnosis. Awareness of the sensitivity and specificity of the various diagnostic tests should lead to the more prudent use of invasive diagnostic tests including angiography and brain biopsy.
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Affiliation(s)
- Susanne Benseler
- Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Ontario, Canada M5G1X8
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Kirton A, Wong JH, Mah J, Ross BC, Kennedy J, Bell K, Hill MD. Successful endovascular therapy for acute basilar thrombosis in an adolescent. Pediatrics 2003; 112:e248-51. [PMID: 12949321 DOI: 10.1542/peds.112.3.e248] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric stroke is an underrecognized, potentially treatable cause of childhood neurologic disease. Acute basilar artery thrombosis is a devastating disease rarely encountered in children. Acute interventions with both chemical and mechanical thrombolysis techniques can improve outcomes in adults with arterial thrombosis of the posterior cerebral circulation. We report a case of intervention with both intra-arterial alteplase (tissue plasminogen activator) and cerebral balloon angioplasty to treat a prolonged basilar artery occlusion secondary to idiopathic thrombosis in an adolescent. Despite the patient being clinically locked-in and intervention being delayed at least 20 hours from symptom onset, he obtained complete neurologic recovery. Issues of pediatric stroke, late therapeutic intervention, chemical thrombolysis, and cerebral angioplasty are discussed. This case highlights the underrecognition and subsequent delay in diagnosis of pediatric stroke and how acute intervention may cure otherwise catastrophic strokes in children.
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Affiliation(s)
- Adam Kirton
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Rosman NP, Adhami S, Mannheim GB, Katz NP, Klucznik RP, Muriello MA. Basilar artery occlusion in children: misleading presentations, "locked-in" state, and diagnostic importance of accompanying vertebral artery occlusion. J Child Neurol 2003; 18:450-62. [PMID: 12940650 DOI: 10.1177/08830738030180070601] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basilar artery occlusion in children is rare. The clinical diagnosis of basilar artery occlusion is often difficult because the initial neurologic findings, most frequently hemiparesis, involuntary movements, or headache, are often transient and can suggest complicated migraine, seizures, or both. We have reviewed 37 previously reported pediatric cases of basilar artery occlusion and present 3 additional ones. In the 40 cases, basilar artery occlusion alone occurred in 22; in the other 18, there was accompanying vertebral artery occlusion. In the cases of pure basilar artery occlusion, the most common causes were trauma and arteritis, but in most such cases, the etiology could not be determined. The cause was found much more often in cases of basilar artery occlusion with accompanying vertebral artery occlusion, with trauma being the most frequent etiology, especially in boys between 6 and 14 years. Of the 37 previously reported pediatric cases of basilar artery occlusion, 7 were "locked in" early in the course (mute, quadriparetic, aware, and communicative with eye movements), as were our 3 cases. In most cases of basilar artery occlusion that are locked in, the basilar artery occlusion involves its midportion, sparing the anterior inferior cerebellar and superior cerebellar arteries.
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Affiliation(s)
- N Paul Rosman
- Department of Pediatrics, The Floating Hospital for Children, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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40
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Hasan I, Wapnick S, Tenner MS, Couldwell WT. Vertebral artery dissection in children: a comprehensive review. Pediatr Neurosurg 2002; 37:168-77. [PMID: 12372909 DOI: 10.1159/000065391] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Vertebral artery dissection (VAD) has been infrequently recognized in children. The authors have reviewed 68 reported cases of VAD in children in the existing literature. An association between routine types of neck movement in sports and the evolution of VAD was recognized in half of the reported cases. Boys outnumbered girls by a ratio of 6.6 to 1, in contrast to adults, for whom the male to female ratio is approximately equal (1.3 to 1). Neck pain, one of the hallmark symptoms of VAD in adults, was infrequently noted in this young population (12%). Most children presented with various combinations of symptoms and signs, including ataxia (53%), headache (38%) and vomiting (34%). Eye signs or symptoms were noted in 72% of patients, and paresis/paralysis of one or more extremity occurred in 54%. Angiography was the method most frequently used to diagnose VAD (63/68; 93%). Magnetic resonance angiography (MRA) revealed pathognomonic signs of VAD in only 3 out of 13 patients evaluated (23%). In this series of 68 patients, 48 reports failed to indicate whether or not a cervical X-ray was performed, but in the 20 patients for whom such information was recorded, half had skeletal abnormalities in the occipital/atlas/axis region. The most common treatments were antiplatelet therapy (n = 15) and anticoagulation with (n = 8) or without (n = 7) supplemental antiplatelet therapy. Asymptomatic recovery occurred in 12 of the 15 patients (80%) who received antiplatelet therapy compared with 4 of the 15 patients (27%) who received anticoagulation therapy with or without antiplatelet therapy. There is a very high incidence of associated cervical anomalies in children with VAD. Further studies are required to determine if noninvasive examinations such as magnetic resonance imaging, ultrasonography, computed tomography angiography and MRA could replace angiography as the modality of choice in establishing the diagnosis of VAD in children. The role of different therapies for children presenting with symptoms related to VAD is unclear.
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Affiliation(s)
- Izhar Hasan
- Department of Neurosurgery, New York Medical College, Valhalla and New York, N.Y., USA
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