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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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2
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Vinarsky V, Sun LR, Yedavalli VS, Schleifer L, Arthur K, Hui F, Harrar DB. Case Report: Successful Anterior Circulation Thrombectomy After 24 Hours in An Adolescent. Pediatr Neurol 2023; 143:64-67. [PMID: 37003190 DOI: 10.1016/j.pediatrneurol.2023.01.014] [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] [Received: 05/01/2022] [Revised: 12/14/2022] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Arterial ischemic stroke in children comes with the potential for morbidity and mortality and can result in high cost of care and decreased quality of life among survivors. Children with arterial ischemic stroke are increasingly being treated with mechanical thrombectomy, but little is known about the risks and benefits 24 hours after a patient's last known well (LKW) time. METHODS A 16-year-old female presented with acute onset of dysarthria and right hemiparesis with LKW time 22 hours prior. Pediatric National Institutes of Health Stroke Scale score was 12. Magnetic resonance imaging showed diffusion restriction and T2 hyperintensity primarily in the left basal ganglia. Magnetic resonance angiography revealed left M1 occlusion. Arterial spin labeling showed a large apparent perfusion deficit. She underwent thrombectomy with TICI3 recanalization 29.5 hours after LKW time. RESULTS At 2-month follow-up, her examination showed moderate right-hand weakness and mild diminished sensation of the right arm. CONCLUSIONS Adult thrombectomy trials include patients up to 24 hours from their LKW time and suggest that some patients maintain a favorable perfusion profile for over 24 hours. Without intervention many go on to experience infarct expansion. The persistence of a favorable perfusion profile likely reflects robust collateral circulation. We hypothesized our patient was relying on collateral circulation to maintain the noninfarcted areas of her left middle cerebral artery territory. Owing to concern for eventual collateral failure, thrombectomy outside of the 24-hour window was performed. This case serves as a call to action to better understand the impact of collateral circulation on cerebral perfusion in children with large vessel occlusions and delineate which children may benefit from thrombectomy in a delayed time window.
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3
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Lu VM, Luther EM, Silva MA, Elarjani T, Abdelsalam A, Maier I, Al Kasab S, Jabbour PM, Kim JT, Wolfe SQ, Rai AT, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Polifka A, Mascitelli J, Osbun J, Park MS, Levitt MR, Dumont T, Cuellar H, Williamson RW, Romano DG, Crosa R, Gory B, Mokin M, Moss M, Limaye K, Kan P, Yavagal DR, Spiotta AM, Starke RM. Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR. J Neurosurg Pediatr 2022; 30:448-454. [PMID: 35986724 DOI: 10.3171/2022.7.peds22250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Evan M Luther
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Michael A Silva
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Turki Elarjani
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ahmed Abdelsalam
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ilko Maier
- 2Department of Neurology, University Medical Center Gottingen, Gottingen, Germany
| | - Sami Al Kasab
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Pascal M Jabbour
- 4Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joon-Tae Kim
- 5Department of Neurosurgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Stacey Q Wolfe
- 6Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ansaar T Rai
- 7Department of Neuroradiology, University of West Virginia, Morgantown, West Virginia
| | | | | | - Adam S Arthur
- 10Department of Neurosurgery, Semmes Murphey Neurologic and Spine Clinic, Memphis, Tennessee
| | - Shinichi Yoshimura
- 11Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Ali Alawieh
- 12Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Isabel Fragata
- 13Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Adam Polifka
- 14Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Justin Mascitelli
- 15Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Joshua Osbun
- 16Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Min S Park
- 17Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael R Levitt
- 18Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Travis Dumont
- 19Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Hugo Cuellar
- 20Department of Radiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Richard W Williamson
- 21Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G Romano
- 22Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerna, Italy
| | - Roberto Crosa
- 23Department of Neurosurgery, Neurological Endovascular Center, Medica Uruguaya, Montevideo, Uruguay
| | - Benjamin Gory
- 24Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- 25Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Mark Moss
- 26Department of Interventional Neuroradiology, Washington Regional Medical, Fayetteville, Arkansas
| | - Kaustubh Limaye
- 27Department of Interventional Neuroradiology, Indiana University, Indianapolis, Indiana; and
| | - Peter Kan
- 28Department of Neurosurgery, University of Texas Medical Branch-Galveston, Galveston, Texas
| | - Dileep R Yavagal
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Alejandro M Spiotta
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Robert M Starke
- 1Department of Neurosurgery, University of Miami, Miami, Florida
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Mayne EW, Mailo JA, Pabst L, Pulcine E, Harrar DB, Waak M, Rafay MF, Hassanein SM, Amlie-Lefond C, Jordan LC. Pediatric Stroke and Cardiac Disease: Challenges in Recognition and Management. Semin Pediatr Neurol 2022; 43:100992. [PMID: 36344023 PMCID: PMC9719802 DOI: 10.1016/j.spen.2022.100992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Elizabeth W Mayne
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA.
| | - Janette A Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Michaela Waak
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia; Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Mubeen F Rafay
- Children's Hospital Winnipeg, University of Manitoba, Children's Hospital Research Institute of Manitoba, Manitoba, Canada
| | - Sahar Ma Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Catherine Amlie-Lefond
- Department of Neurology, Department of Neurological Surgery, University of Washington, Seattle, WA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
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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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7
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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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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Harrar DB, Benedetti GM, Jayakar A, Carpenter JL, Mangum TK, Chung M, Appavu B. Pediatric Acute Stroke Protocols in the United States and Canada. J Pediatr 2022; 242:220-227.e7. [PMID: 34774972 DOI: 10.1016/j.jpeds.2021.10.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures. STUDY DESIGN We administered an Internet-based survey of pediatric stroke specialists. The survey included questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke response, imaging, and hyperacute treatment. RESULTS Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke. Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing, the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page. Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbreviated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator (IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey. CONCLUSIONS An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.
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Affiliation(s)
- Dana B Harrar
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Giulia M Benedetti
- Department of Neurology, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Tara K Mangum
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
| | - Melissa Chung
- Divisions of Critical Care Medicine and Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Brian Appavu
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
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11
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Complete functional recovery in a child after endovascular treatment of basilar artery occlusion caused by spontaneous dissection: a case report. Childs Nerv Syst 2022; 38:1605-1612. [PMID: 34893933 PMCID: PMC9325841 DOI: 10.1007/s00381-021-05428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/29/2021] [Indexed: 10/26/2022]
Abstract
Stroke caused by dissection of arteries of the vertebrobasilar system in children is still poorly investigated in terms of etiology, means of treatment, course of disease, and prognosis. The aim of this report was to describe the unusual course of a spontaneous dissection of the basilar artery (BA) in a child treated with endovascular techniques and to point out that the plasticity of the brain stem can fully compensate for structural damage caused by stroke. We report the case of a 15-year-old boy who suffered a wake-up stroke with BA occlusion caused by spontaneous dissection. A blood clot was aspirated from the false lumen and the true lumen re-opened, but the patient deteriorated a few hours later, and repeated angiography revealed that the intimal flap was detached, occluding the BA again. The lumen of BA was then reconstructed by a stent. Despite a large pons infarction, the patient was completely recovered 11 months after the onset. The case was analyzed with angiograms and magnetic resonance imaging, macroscopic and microscopic pathological analysis, computed tomographic angiography, magnetic resonance-based angiography, and diffusion tensor imaging. This case illustrates that applied endovascular techniques and intensive care measures can alter the course of potentially fatal brain stem infarction. Our multimodal analysis gives new insight into the anatomical basis for the plasticity mechanism of the brain stem.
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12
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Dalai S, Limaye U, Kolli S, Maturu MVS, Narayana RV, Pati R, Korada SK, Vankineni K, Sameera A, Datla AV. Endovascular Treatment of Acute Ischemic Stroke in Patients Younger than 18 Years. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1740568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractRapid and effective revascularization is very important in the treatment of acute ischemic stroke (AIS). Endovascular treatment is a promising modality in the management of AIS in young patients. We evaluated the clinical and imaging records in 14 patients younger than 18 years presenting within 6 hours of AIS. They received endovascular therapy (ET) either by mechanical thrombectomy, thromboaspiration, or both (Solumbra) between July 2017 and June 2021 in our institute. The National Institute of Health Stroke Scale (NIHSS) score was calculated on admission and before the discharge of all patients. The 90-day modified Rankin Scale (mRS) score on disability-free outcome was also evaluated. The mean preprocedure NIHSS score was 10.78 ± 2.11 that improved to 4.5 ± 1.88 after the procedure. Thrombolysis in cerebral infarction (TICI) grade 2b and 3 blood flow could be established in 12 (85.72%) patients. One patient had TICI 2a flow and one patient had recurrent occlusion despite repeated recanalization (TICI grade 0). The disability-free outcome, mRS score at 90 days was 0 to 1 in 12 (85.72%) patients, mRS score 2 in one (7.14%) patient, and mRS score 3 in one patient (7.14%). We did not have any major complication related to the procedure. ET provides high rates of arterial recanalization and favorable disability-free outcomes in young patients with AIS.
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Affiliation(s)
- Sibasankar Dalai
- Department of Interventional Neuroradiology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Uday Limaye
- Department of Neurointervention, Lilavati Hospital, Mumbai, Maharashtra, India
| | - Satyarao Kolli
- Department of Neurology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | | | | | - Rajesh Pati
- Department of Neurology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Suresh Kumar Korada
- Department of Neurology, Seven Hills Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Kuchelababu Vankineni
- Department of Anaesthesiology and Critical Care, Seven Hills Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Anantamakula Sameera
- Department of Radiodiagnosis, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Aravind Varma Datla
- Department of Internal Medicine, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
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Deng Y, Liu G, Zhang G, Xu J, Yao C, Wang L, Zhao C, Wang Y. Childhood strokes in China describing clinical characteristics, risk factors and performance indicators: a case-series study. Stroke Vasc Neurol 2021; 7:140-148. [PMID: 34862326 PMCID: PMC9067266 DOI: 10.1136/svn-2021-001062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/09/2021] [Indexed: 11/04/2022] Open
Abstract
AIM To investigate clinical characteristics, risk factors (RFs), neurologic deficits and medical care provided in children who had a stroke in China. METHODS We conducted a retrospective case-series study using the medical records of children aged 1 month to 18 years with arterial ischaemic stroke (AIS) or haemorrhagic stroke (HS) (with the entry codes I60, I61, I62, I63 (ICD-10)), who were admitted to different hospitals in Beijing, between January 2018 and December 2018. We obtained the following information from the charts: demographic characteristics, clinical presentations, RFs for paediatric stroke, laboratory examination, neuroimaging records and neurologic sequelae. RESULTS We identified 312 first admissions for stroke (172 AIS and 140 HS). The mean age at onset was 8.6±3.9 years for patients who had an AIS and 8 (5-13) years for patients who had an HS. There were more males than females in both groups (AIS: 59.88% vs 40.12%; HS: 52.14% vs 47.86%). A known aetiology was identified in 92.44% and 86.43% of patients who had an AIS and HS, respectively. The leading cause of AIS was cerebrovascular diseases including moyamoya (68.6%), while that for HS was arteriovenous malformation (51.43%). The most common initial clinical presentation was hemiplegia (86.05%) in patients who had an AIS and headache (67.86%) in patients who had an HS. The use of healthcare, including acute treatment (antithrombotic in 17.44%, anticoagulant in 5.23%) and secondary prevention (antithrombotic in 6.39%, anticoagulant in 1.16%), varied and was significantly lower among patients who had an AIS. The most common complications were epilepsy (22.09%) and pneumonia (4.65%) in patients who had an AIS and epilepsy (17.14%) and hydrocephalus (12.14%) in patients who had an HS. Neurological deficits occurred in 62.8% of patients who had an AIS and 72.86% of patients who had an HS. CONCLUSION Cerebral arteriopathy was a major RF for both AIS and HS in children living in China. Large epidemiological studies are required to identify RFs to prevent stroke as well as appropriate interventions.
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Affiliation(s)
- Yaxian Deng
- Department of Pediatrics, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
| | - Gaifen Liu
- China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Guitao Zhang
- Department of Neurology, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
| | - Juanyu Xu
- Department of Pediatrics, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
| | - Chunmei Yao
- Department of Pediatrics, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
| | - Lei Wang
- Department of Pediatrics, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
| | - Chengsong Zhao
- Outpatient Department, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hosppital Affiliated to Capital Medical University, Beijing, China
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14
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Chen K, Dawkins D, Orbach DB, Aagaard-Kienitz B. Low profile sheaths in pediatric neurointervention: a multicenter experience. J Neurointerv Surg 2021; 14:1135-1138. [PMID: 34625510 DOI: 10.1136/neurintsurg-2021-017936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population. METHODS All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced. RESULTS From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05). CONCLUSION The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.
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Affiliation(s)
- Karen Chen
- Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Demi Dawkins
- Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beverly Aagaard-Kienitz
- Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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15
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Heit JJ, Muthusami P, Chandra RV, Hui F, Negrotto M, Lee S, Wasserman BA, Abruzzo TA. Reperfusion Therapies for Children With Arterial Ischemic Stroke. Top Magn Reson Imaging 2021; 30:231-243. [PMID: 34613946 DOI: 10.1097/rmr.0000000000000273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Modern hyperacute reperfusion therapies including intravenous thrombolysis and mechanical thrombectomy have transformed the management of arterial ischemic stroke (AIS) in adults. Multiple randomized clinical trials have demonstrated that these therapies enable remarkable improvements in clinical outcome for properly selected patients with AIS. Because pediatric patients were excluded from predicate clinical trials, there is a conspicuous lack of data to guide selection of therapies and inform age-adjusted and pathology-oriented treatment modifications for children. Specifically, technical guidance concerning treatment eligibility, drug dosing, and device implementation is lacking. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with therapeutic decision making.
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Affiliation(s)
- Jeremy J Heit
- Department of Radiology, Stanford University Medical Center, Stanford, CA.,Department of Neurosurgery, Stanford University Medical Center, Stanford, CA
| | | | - Ronil V Chandra
- Monash University Medical Center, Monash University, Melbourne, Australia
| | - Ferdinand Hui
- Johns Hopkins University Medical Center, Baltimore, MD
| | | | - Sarah Lee
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Abruzzo
- Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ.,University of Arizona School of Medicine, Phoenix, AZ.,Mayo Clinic College of Medicine, Phoenix, AZ
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16
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Treatment Efficacy Analysis in Acute Ischemic Stroke Patients Using In Silico Modeling Based on Machine Learning: A Proof-of-Principle. Biomedicines 2021; 9:biomedicines9101357. [PMID: 34680474 PMCID: PMC8533087 DOI: 10.3390/biomedicines9101357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 01/08/2023] Open
Abstract
Interventional neuroradiology is characterized by engineering- and experience-driven device development with design improvements every few months. However, clinical validation of these new devices requires lengthy and expensive randomized controlled trials. This contribution proposes a machine learning-based in silico study design to evaluate new devices more quickly with a small sample size. Acute diffusion- and perfusion-weighted MRI, segmented one-week follow-up imaging, and clinical variables were available for 90 acute ischemic stroke patients. Three treatment option-specific random forest models were trained to predict the one-week follow-up lesion segmentation for (1) patients successfully recanalized using intra-arterial mechanical thrombectomy, (2) patients successfully recanalized using intravenous thrombolysis, and (3) non-recanalizing patients as an analogue for conservative treatment for each patient in the sample, independent of the true group membership. A repeated-measures analysis of the three predicted follow-up lesions for each patient revealed significantly larger lesions for the non-recanalizing group compared to the successful intravenous thrombolysis treatment group, which in turn showed significantly larger lesions compared to the successful mechanical thrombectomy treatment group (p < 0.001). A groupwise comparison of the true follow-up lesions for the three treatment options showed the same trend but did not reach statistical significance (p = 0.19). We conclude that the proposed machine learning-based in silico trial design leads to clinically feasible results and can support new efficacy studies by providing additional power and potential early intermediate results.
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17
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Olivieri M, Sorg AL, Weinberger R, Kurnik K, Bidlingmaier C, Juranek S, Hoffmann F, Reiter K, Bonfert M, Tacke M, Borggraefe I, Heinen F, Gerstl L. Recanalization strategies in childhood stroke in Germany. Sci Rep 2021; 11:13314. [PMID: 34172782 PMCID: PMC8233321 DOI: 10.1038/s41598-021-92533-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/11/2021] [Indexed: 12/21/2022] Open
Abstract
Childhood arterial ischemic stroke (CAIS) is a rare event. Diverse etiologies, risk factors, symptoms and stroke mimics hamper obtaining a fast diagnosis and implementing immediate recanalization strategies. Over a period of 3 years (2015–2017), the data of 164 pediatric patients (> 28 days of life-18 years) with a first episode of AIS were submitted to a hospital-based nationwide surveillance system for rare disorders (ESPED). We report a subgroup analysis of patients who have undergone recanalization therapy and compare these data with those of the whole group. Twenty-eight patients (17%) with a median age of 12.2 years (range 3.3–16.9) received recanalization therapy. Hemiparesis, facial weakness and speech disturbance were the main presenting symptoms. The time from onset of symptoms to confirmation of diagnosis was significantly shorter in the intervention group (4.1 h vs. 20.4 h, p ≤ 0.0001). Only in one patient occurred a minor bleed. Cardiac disease as predisposing risk factor was more common in the recanalization group. Recanalization therapies are feasible and increasingly applied in children with AIS. High awareness, timely diagnosis and a large amount of expertise may improve time to treatment and make hyperacute therapy an option for more patients.
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Affiliation(s)
- Martin Olivieri
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany.
| | - Anna-Lisa Sorg
- Institute of Social Pediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Raphael Weinberger
- Institute of Social Pediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Karin Kurnik
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Christoph Bidlingmaier
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Sabrina Juranek
- Pediatric Hemostasis and Thrombosis Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Florian Hoffmann
- Pediatric Intensive Care Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Karl Reiter
- Pediatric Intensive Care Unit, Department of Pediatrics, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Michaela Bonfert
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Moritz Tacke
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ingo Borggraefe
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Florian Heinen
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Development and Children With Medical Complexity, Dr Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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18
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Kopyta I, Cebula A, Sarecka-Hujar B. Early Deaths after Arterial Ischemic Stroke in Pediatric Patients: Incidence and Risk Factors. CHILDREN-BASEL 2021; 8:children8060471. [PMID: 34204895 PMCID: PMC8228712 DOI: 10.3390/children8060471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/29/2021] [Accepted: 05/31/2021] [Indexed: 01/02/2023]
Abstract
In developed countries, cerebrovascular diseases are among the 10 most common causes of death in both the pediatric and adult population. The prevalence of fatal outcomes following arterial ischemic stroke (AIS) in various groups of pediatric patients ranges from 1% to almost 32%. However, a constant improvement in stroke mortality among children has been observed. The extent of the decline differs among studies (from nearly tenfold to twofold decline), as it depends on the study population. While a portion of this variability might be explained by factors such as health care access, population age, diseases related to ethnicity, and different etiologies of stroke in studied populations, the understanding of such differences is still insufficient. Risk factors for death in the early stages of the disease are poorly understood and are usually based on the clinical presentations of relatively small groups of pediatric patients. Familiarity with these factors may be of significant importance for prognosis, but also for the early selection of patients requiring careful supervision. The present study aimed to analyze and discuss the current literature data on the incidence of early death and risk factors for early death in children suffering from stroke.
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Affiliation(s)
- Ilona Kopyta
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Agnieszka Cebula
- Department of Paediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland; (I.K.); (A.C.)
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence:
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19
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Nasr N, Delamarre L, Cheuret E, Chausseray G, Olivot JM, Acar P, Bonneville F. Case Report: Late Successful Thrombectomy for Ischemic Stroke in a 2-Year-Old Child. Front Neurol 2021; 12:670565. [PMID: 34122315 PMCID: PMC8193682 DOI: 10.3389/fneur.2021.670565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Despite extensive evidence of benefit of thrombectomy in adult ischemic stroke due to large-vessel occlusion in the 6-h window, its role remains uncertain in very young children. We describe hereafter the case of a 2-year-old female child who had a successful thrombectomy 9 h after stroke onset. The patient presented with right hemiplegia, central facial palsy, a normal level of consciousness, and speech difficulties. The PedNIHS score was 11. CT scan without contrast injection displayed spontaneous hyperdensity of the middle cerebral artery (MCA), with only limited early signs of ischemia (ASPECTS 8). CT angiography demonstrated occlusion of the proximal MCA with good collaterals. Thrombectomy was realized. Complete recanalization (TICI 3) was obtained under general anesthesia after two passes of a stent retriever. Time from symptoms onset to full recanalization was 9 h. The acute ischemic stroke was caused by embolic thrombus from a congenital heart disease. Clinical recovery was complete. Three months after the thrombectomy, the young patient was doing well without any neurological sequelae (PedNIHSS 0; modified Rankin Scale: 0). This case report is an example of a decision-making process to perform thrombectomy in a very young child, which included cardio-embolic etiology as a parameter that potentially might have participated to the successful outcome of the therapeutic procedure.
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Affiliation(s)
- Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, Université Toulouse III, INSERM UMR 1048, Toulouse, France
| | - Louis Delamarre
- Department of Anesthesiology and Intensive Care, Toulouse University Hospital, Toulouse, France
| | - Emmanuel Cheuret
- Department of Pediatry, Pediatric Neurology Unit, Toulouse University Hospital, Toulouse, France
| | - Gerald Chausseray
- Department of Anesthesiology and Intensive Care, Toulouse University Hospital, Toulouse, France
| | - Jean Marc Olivot
- Department of Neurology, Toulouse University Hospital, Université Toulouse III, Toulouse, France
| | - Philippe Acar
- Department of Pediatry, Pediatric Cardiology Unit, Toulouse University Hospital, Université Toulouse III, Toulouse, France
| | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, Université Toulouse III, Toulouse, France
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20
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Gailloud P, Pearl MS. Endovascular therapy for acute stroke in children: age and size technical limitations. J Neurointerv Surg 2021; 13:794-798. [PMID: 33832970 DOI: 10.1136/neurintsurg-2021-017311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
Endovascular therapies for acute childhood stroke remain controversial and little evidence exists to determine the minimum age and size cut-off for thrombectomy in children. Despite this, an increasing number of reports suggest feasibility of thrombectomy in at least some children by experienced operators. When compared with adults, technical modifications may be necessary in children owing to differences in vessel sizes, tolerance of blood loss, safety of contrast and radiation exposure, and differing stroke etiologies. We review critical considerations for neurologists and neurointerventionalists when treating pediatric stroke with endovascular therapies. We discuss technical factors that may limit feasibility of endovascular therapy, including size of the femoral and cervicocerebral arteries, which contributes to vasospasm risk. The risk of femoral vasospasm can be assessed by comparing catheter outer diameter with estimated femoral artery size, which can be estimated based on the child's height. We review evidence supporting specific strategies to mitigate cervicocerebral arterial injury, including technique (stent retrieval vs direct aspiration) and device size selection. The importance of and strategies for minimizing blood loss, radiation exposure, and contrast administration are reviewed. Attention to these technical limitations is critical to delivering the safest possible care when thrombectomy is being considered for children with acute stroke.
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Affiliation(s)
- Lisa R Sun
- Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana Harrar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Gerald Drocton
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Philippe Gailloud
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA.,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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21
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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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22
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Nesbit GM. Neurovascular disease and syndromes: Diagnosis and therapy in children. HANDBOOK OF CLINICAL NEUROLOGY 2020; 176:305-323. [PMID: 33272401 DOI: 10.1016/b978-0-444-64034-5.00015-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pediatric neurovascular disease runs the chronologic spectrum with dramatic changes in the presentation, evaluation, and treatment from the prenatal, perinatal, and infant periods through childhood and adolescence. These diseases are often dynamic throughout this period and the dynamic continues throughout life. There are four major categories: high-flow arteriovenous shunting lesions, arterial aneurysms, low-flow vascular lesions, and vascular occlusive disease. The high-flow lesions can be subdivided into a vein of Galen malformation, non-Galenic arteriovenous fistula, dural sinus malformations and fistula, and arteriovenous malformation. Low-flow vascular lesions include cerebral cavernous malformation, developmental venous anomaly, and capillary telangiectasia. The cerebrovascular occlusive disease can be divided between arterial occlusive disease and cerebral venous sinus thrombosis. The presentation of each of these entities can be very similar, especially in younger children; however, imaging and laboratory analysis can establish the diagnosis leading to the most appropriate therapy. A multidisciplinary team, dedicated to treating pediatric cerebrovascular disease, is important in delivering the best outcomes in these complex diseases. Given the relative rarity of pediatric presentation of cerebrovascular disease, many apply adult concepts to children. A better understanding of the diseases and their difference from adults makes a critical difference in selecting the correct approach.
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Affiliation(s)
- Gary M Nesbit
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, United States.
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical Thrombectomy for Acute Ischemic Stroke: Considerations in Children. Stroke 2020; 51:3174-3181. [PMID: 32912096 DOI: 10.1161/strokeaha.120.029698] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Dana Harrar
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gerald Drocton
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Carlos Castillo-Pinto
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Ryan Felling
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care and Pediatric Cardiology, Children's National Hospital, Washington, DC. (G.W.)
| | - Cameron G McDougall
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD. (C.G.M.)
| | - Philippe Gailloud
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Monica S Pearl
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.).,Department of Radiology, Children's National Hospital, Washington, DC. (M.S.P.)
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24
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Harrar DB, Salussolia CL, Kapur K, Danehy A, Kleinman ME, Mannix R, Rivkin MJ. A Stroke Alert Protocol Decreases the Time to Diagnosis of Brain Attack Symptoms in a Pediatric Emergency Department. J Pediatr 2020; 216:136-141.e6. [PMID: 31704052 DOI: 10.1016/j.jpeds.2019.09.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether a stroke alert system decreases the time to diagnosis of children presenting to the emergency department (ED) with acute-onset focal neurologic deficits. STUDY DESIGN We performed a retrospective comparison of clinical and demographic information for patients who presented to the ED of a tertiary children's hospital with acute-onset focal neurologic deficits during the 2.5 years before (n = 14) and after (n = 65) the implementation of a stroke alert system. The primary outcome was the median time to neuroimaging analyzed using a Wilcoxon rank-sum test. RESULTS The median time from ED arrival to neuroimaging for patients with acute-onset focal neurologic deficits decreased significantly after implementation of a stroke alert system (196 minutes; IQR, 85-230 minutes before [n = 14] vs 82 minutes; IQR, 54-123 minutes after [n = 65]; P < .01). Potential intravenous tissue plasminogen activator candidates experienced the shortest time to neuroimaging after implementation of a stroke alert system (54 minutes; IQR, 34-66 minutes [n = 13] for intravenous tissue plasminogen activator candidates vs 89.5 minutes; IQR, 62-126.5 minutes [n = 52] for non-intravenous tissue plasminogen activator candidates; P < .01). CONCLUSIONS A stroke alert system decreases the median time to diagnosis by neuroimaging of children presenting to the ED with acute-onset focal neurologic deficits by more than one-half. Such a protocol constitutes an important step in ensuring that a greater proportion of children with arterial ischemic stroke are diagnosed in a time frame that enables hyperacute treatment.
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Affiliation(s)
- Dana B Harrar
- Department of Neurology, Boston Children's Hospital, Boston, MA; Stroke and Cerebrovascular Center, Boston Children's Hospital, Boston, MA.
| | | | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Amy Danehy
- Stroke and Cerebrovascular Center, Boston Children's Hospital, Boston, MA; Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Monica E Kleinman
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Rebekah Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, MA; Stroke and Cerebrovascular Center, Boston Children's Hospital, Boston, MA; Department of Radiology, Boston Children's Hospital, Boston, MA; Department of Psychiatry, Boston Children's Hospital, Boston, MA
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25
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Buonomo O, Caragliano AA, Tessitore A, Pitrone A, Vinci SL. A Multidisciplinary Approach in the Management of a Paediatric Posterior Fossa Ischaemic Stroke: A Case Report. Cureus 2019; 11:e6418. [PMID: 31988819 PMCID: PMC6970101 DOI: 10.7759/cureus.6418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/19/2019] [Indexed: 01/01/2023] Open
Abstract
Posterior circulation acute ischaemic stroke in childhood is a rare but life-threatening disease. We describe a paediatric case of a 17-year-old Indian boy who was admitted to our centre for headache, nausea, vomiting, asthenia, and fever for two days. Computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) were performed, showing a thrombotic occlusion of the basilar artery due to focal dissection into the proximal third of the left vertebral artery. In a multidisciplinary fashion, we decided to perform a direct aspiration first pass technique (ADAPT), which led to the complete recanalization of either the left vertebral artery or the basilar artery. Twenty-four hours later, despite the anti-edemigenic medical therapy, a preventive occipital craniectomy was performed because of the presence of cerebral oedema to avoid the possible worsening of the patient and compression on the brainstem. Our experience emphasizes the importance of a multidisciplinary and preventive approach in the management of a paediatric posterior fossa ischaemic stroke.
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Affiliation(s)
- Orazio Buonomo
- Neuroradiology Unit, Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, ITA
| | - Antonio Armando Caragliano
- Neuroradiology Unit, Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, ITA
| | - Agostino Tessitore
- Neuroradiology Unit, Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, ITA
| | - Antonio Pitrone
- Neuroradiology Unit, Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, ITA
| | - Sergio Lucio Vinci
- Neuroradiology Unit, Biomedical Sciences and Morphologic and Functional Images, University of Messina, Messina, ITA
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26
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Gervelis WL, Golomb MR. Mechanical Thrombectomy in Pediatric Stroke: Report of Three New Cases. J Stroke Cerebrovasc Dis 2019; 29:104551. [PMID: 31843352 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/01/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children. METHODS We report 3 new cases of pediatric stroke treated using mechanical thrombectomy. Two cases of AIS and 1 case of CVT were identified from 2018 pediatric stroke clinic records. RESULTS Thrombectomy was successful in 1 of the 2 AIS cases and in the CVT case. None of the children were asymptomatic after thrombectomy. One AIS case had good recovery than developed dystonia which responded to treatment; the second AIS case had residual hemiplegia; and the child with CVT had mild school problems. CONCLUSIONS Mechanical thrombectomy is being increasingly used for pediatric stroke treatment. This study and recent literature reviews suggest thrombectomy holds promise as a treatment for selected pediatric stroke patients. Questions remain about the safety and efficacy of thrombectomy in children with stroke since large randomized controlled studies are not yet feasible.
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Affiliation(s)
- Whitney L Gervelis
- Division of Child Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Meredith R Golomb
- Division of Child Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana.
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Wilson JL, Amlie-Lefond C, Abruzzo T, Orbach DB, Rivkin MJ, deVeber GA, Pergami P. Survey of practice patterns and preparedness for endovascular therapy in acute pediatric stroke. Childs Nerv Syst 2019; 35:2371-2378. [PMID: 31482313 DOI: 10.1007/s00381-019-04358-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Endovascular therapy benefits selected adults with acute stroke while data are lacking for children. The purpose of this study was to assess physician practice and institutional preparedness for endovascular therapy in pediatric stroke. METHODS A link to an anonymous online survey was sent to members of the International Pediatric Stroke Study (IPSS) group about physician experience with endovascular therapy, likelihood of treatment for provided clinical vignettes, and institutional readiness for the delivery of endovascular therapy to children. RESULTS Thirty-one pediatric physicians with a mean of 11 years (SD 7.1) of experience responded. All but two would consider endovascular therapy in a child, and 20 (64.5%) had recommended endovascular therapy for a child in the preceding year. Most (n = 19, 67.9%) did not commit to an age minimum for endovascular therapy. Sixteen (57.1%) would consider treatment up to 24 h after symptom onset with 19 (67.9%) respondents reporting that their practice changed after the 2018 American Heart Association guidelines extended the time window for endovascular therapy in adults. Seventeen (60.7%) preferred imaging that included perfusion in children presenting beyond 6 h. Nineteen (70.4%) had institutional endovascular therapy criteria. Physicians in larger pediatric groups had more "likely to treat" responses on the clinical vignettes than physicians working in smaller groups (11.7 vs. 6.1, p < 0.05). CONCLUSION Pediatric stroke physicians are largely willing to consider endovascular therapy with most changing their practice according to adult guidelines, though experience and selection criteria varied. These findings may help to inform consensus guidelines and clinical trial development.
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Affiliation(s)
- Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University, 707 SW Gaines St, Portland, OR, 97239, USA.
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Hospital, Mayo Clinic College of Medicine and University of Arizona, Tucson, AZ, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Rivkin
- Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, Boston, MA, USA
| | | | - Paola Pergami
- Pediatric Neurology, MedStar Georgetown University Hospital and Department of Neurology, Children's National Medical Center, Washington, DC, USA
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28
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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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