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Kossorotoff M, Grévent D, Roux CJ, Brunelle F. Development of Collateral Vessels after Anterior Circulation Large Vessel Occlusion in Pediatric Arterial Ischemic Stroke Relates to Stroke Etiology: A Longitudinal Study. AJNR Am J Neuroradiol 2024; 45:271-276. [PMID: 38388687 DOI: 10.3174/ajnr.a8114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/01/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE The characteristics of large vessel occlusion (LVO) in the acute phase of pediatric arterial ischemic stroke and their natural history according to stroke etiology are poorly explored. This studied aimed at describing the prevalence and the radiological evolution of LVO in pediatric AIS. MATERIALS AND METHODS This single-center retrospective study included consecutive non-neonate children with acute arterial ischemic stroke, intracranial proximal LVO in the anterior circulation (MCA, anterior cerebral artery, and/or ICA), and clinical and imaging follow-up for at least 18 months, during a 9-year period. RESULTS Intracranial LVO was observed in 24.8% of patients with anterior circulation arterial ischemic stroke and adequate follow-up (n = 26/105), with a median age of 4.2 years (IQR 0.8-9), sex ratio 1.16. The main stroke etiology associated with LVO was unilateral focal cerebral arteriopathy (n = 12, 46%). During follow-up, a specific pattern of unilateral poststroke anastomotic bridge was observed in 8/26 patients, with the poststroke development of nonperforating collaterals forming a bridge in bypass of the LVO site with visible distal flow, within a median delay of 11 months. The development of unilateral poststroke anastomotic bridge was only observed in patients with unilateral focal cerebral arteriopathy. No patient with this pattern experienced stroke recurrence or further progressive vascular modifications. CONCLUSIONS After stroke, the development of unilateral poststroke anastomotic bridge is specifically observed in children with focal cerebral arteriopathy, appearing in the first year after stroke. This clinical-radiologic pattern was not associated with stroke recurrence or arterial worsening, differentiating it from progressive intracranial arteriopathy, such as Moyamoya angiopathy.
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Affiliation(s)
- Manoëlle Kossorotoff
- From the French Center for Pediatric Stroke (M.K., C.-J.R.), Paris, France
- Pediatric Neurology Department (M.K.), APHP University Hospital Necker-Enfants Malades, Paris, France
- INSERM U1266 (M.K.), Paris, France
| | - David Grévent
- Pediatric Radiology Department (D.G., C.-J.R., F.B.), APHP University Hospital Necker-Enfants Malades, Paris, France
| | - Charles-Joris Roux
- From the French Center for Pediatric Stroke (M.K., C.-J.R.), Paris, France
- Pediatric Radiology Department (D.G., C.-J.R., F.B.), APHP University Hospital Necker-Enfants Malades, Paris, France
| | - Francis Brunelle
- Pediatric Radiology Department (D.G., C.-J.R., F.B.), APHP University Hospital Necker-Enfants Malades, Paris, France
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Pacchiano F, Tortora M, Criscuolo S, Jaber K, Acierno P, De Simone M, Tortora F, Briganti F, Caranci F. Artificial intelligence applied in acute ischemic stroke: from child to elderly. Radiol Med 2024; 129:83-92. [PMID: 37878222 PMCID: PMC10808481 DOI: 10.1007/s11547-023-01735-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023]
Abstract
This review will summarize artificial intelligence developments in acute ischemic stroke in recent years and forecasts for the future. Stroke is a major healthcare concern due to its effects on the patient's quality of life and its dependence on the timing of the identification as well as the treatment. In recent years, attention increased on the use of artificial intelligence (AI) systems to help categorize, prognosis, and to channel these patients toward the right therapeutic procedure. Machine learning (ML) and in particular deep learning (DL) systems using convoluted neural networks (CNN) are becoming increasingly popular. Various studies over the years evaluated the use of these methods of analysis and prediction in the assessment of stroke patients, and at the same time, several applications and software have been developed to support the neuroradiologists and the stroke team to improve patient outcomes.
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Affiliation(s)
- Francesco Pacchiano
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Caserta, Italy
| | - Mario Tortora
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy.
| | - Sabrina Criscuolo
- Pediatric University Department, Bambino Gesù Children Hospital, Rome, Italy
| | - Katya Jaber
- Department of Elektrotechnik und Informatik, Hochschule Bremen, Bremen, Germany
| | | | - Marta De Simone
- UOC Neuroradiology, AORN San Giuseppe Moscati, Avellino, Italy
| | - Fabio Tortora
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Francesco Briganti
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Ferdinando Caranci
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Caserta, Italy
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de Castro PDC, Lopez MV, Nuñez AG, Maria ACP, Herrero CM. Acute recanalization treatments in postnatal paediatric ischaemic arterial stroke. Paediatric stroke code. An Pediatr (Barc) 2023:S2341-2879(23)00132-1. [PMID: 37344305 DOI: 10.1016/j.anpede.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/15/2023] [Indexed: 06/23/2023] Open
Abstract
In children, arterial ischemic stroke is a much less understood disease compared to in adults due to its lower frequency and different aetiology. However, it is also a serious disease, with a high incidence of severe and permanent sequelae that exceeds 50% of total cases. The acute management of postnatal arterial ischaemic stroke (MNAIS) has changed drastically in recent years, chiefly on account of recanalization treatments (thrombolysis and endovascular therapies). These treatments, which used to not be recommended in childhood, are increasingly implemented in everyday clinical practice. Although the evidence from studies carried out in children is not of high quality due to their retrospective design and the small number of reported cases, they support the hypothesis that these treatments are as safe and effective as they are in adults as long as appropriate eligibility criteria are applied and they are used within a certain time from the onset of symptoms (therapeutic window). This article reviews the acute management of postnatal paediatric arterial ischemic stroke based on the current scientific evidence. Since the efficacy of these treatments is highly dependent on their early initiation, a paediatric stroke code needs to be in place as an extension of the stroke code applied to adults. It has started to be introduced in Spain since 2019, although there are still large areas of the country where it has yet to be applied.
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Mills MG, Reichhold A, Maciorowski K, Joong A, Kurz J, Pardo AC. Stroke Diagnosis Protocol for Children With Ventricular Assist Devices. ASAIO J 2023; 69:e199-e204. [PMID: 36696479 DOI: 10.1097/mat.0000000000001858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Ventricular assist devices (VADs) are increasingly used for end-stage heart failure in children. VAD-associated neurologic dysfunction, including stroke and intracranial hemorrhage, occurs in more than 20% of patients. Starting in 2019, we implemented a protocol to diagnose stroke in relation to VAD to facilitate treatment. A multidisciplinary approach was implemented including targeted education for providers. VAD goals, structured neurologic exam, and frequency of neuromonitoring were incorporated into daily rounds, tailored to patient's phase of recovery. A protocolized neurocritical team assessment was implemented. A VAD-specific stroke algorithm and order set were implemented to facilitate rapid neuroimaging. We performed a pre- and postimplementation analysis from 2015 to 2020. Forty-six patients had VADs placed, 25 preintervention, and 21 postintervention. We compared the number of patients evaluated for stroke, time to imaging, and documentation of last known normal exam. Preintervention, time to imaging was 7 hours, and documentation was inconsistent. Postintervention, time to imaging decreased to 2.8 hours ( p = 0.038) with universal documentation of last known normal ( p = 0.009). The use of head computerized tomographies decreased from 11 preintervention to three postintervention. Development of a VAD protocol decreased time to imaging for suspected stroke and reduced unnecessary imaging. Further studies are required to validate these data.
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Affiliation(s)
- Michele G Mills
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Allison Reichhold
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Heart Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Kim Maciorowski
- Center for Quality and Safety, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anna Joong
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan Kurz
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Merck & Co., Kenilworth, New Jersey
| | - Andrea C Pardo
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bindslev JB, Hansen K, Laugesen NG, Benndorf G, Hoei-Hansen CE, Truelsen T. Acute triage of childhood stroke in Denmark. Eur Stroke J 2023; 8:483-491. [DOI: 10.1177/23969873231161381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Objective: This 2-year observational study aimed to test the feasibility of implementing a pediatric stroke triage-setup that connected frontline providers with vascular neurologists and to examine final diagnoses in children triaged for suspected stroke. Methods: Prospective, consecutive registration of children with suspected stroke triaged by a team of vascular neurologists from Jan 1st, 2020 and through Dec 2021, Eastern Denmark (census 530,000 children). Based on the provided clinical information, the children were triaged to either assessment at the Comprehensive Stroke Center (CSC) in Copenhagen or to a pediatric department. All included children were retrospectively followed-up for clinical presentations and final diagnosis. Results: A total of 163 children with 166 suspected stroke events were triaged by the vascular neurologists. Cerebrovascular disease was present in 15 (9.0%) suspected stroke events; one child had intracerebral hemorrhage, one had subarachnoid hemorrhage, two children presented with three TIA events and nine children presented with 10 ischemic stroke events. Two children with ischemic stroke were eligible for acute revascularization treatment of which both were triaged to the CSC. The sensitivity of the triage by acute revascularization indication was 1.00 (95% confidence interval (95% CI): 0.15–1.00) and specificity 0.65 (95% CI: 0.57–0.73). Non-stroke neurological emergencies were present in 34 (20.5%) children, including seizures in 18 (10.8%) and acute demyelinating disorders in 7 (4.2%). Conclusion: Implementing regional triage-setup that connected frontline providers to vascular neurologists was feasible; this system was activated for the majority of children with ischemic stroke according to an expected incidence and led to identification of children eligible for revascularization treatments.
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Affiliation(s)
- Julie Brix Bindslev
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Goetz Benndorf
- Department of Radiology, University Hospital of Copenhagen, Rigshopitalet, Copenhagen, Denmark
- Baylor College of Medicine, Houston, TX, USA
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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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] [What about the content of this article? (0)] [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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Surtees TL, Pearson R, Harrar DB, Lee S, Amlie-Lefond CM, Guilliams KP. 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] [What about the content of this article? (0)] [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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Kossorotoff M, Kerleroux B, Boulouis G, Husson B, Tran Dong K, Eugene F, Damaj L, Ozanne A, Bellesme C, Rolland A, Bourcier R, Triquenot-Bagan A, Marnat G, Neau JP, Joriot S, Perez A, Guillen M, Perivier M, Audic F, Hak JF, Denier C, Naggara O. Recanalization Treatments for Pediatric Acute Ischemic Stroke in France. JAMA Netw Open 2022; 5:e2231343. [PMID: 36107427 PMCID: PMC9478769 DOI: 10.1001/jamanetworkopen.2022.31343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS). OBJECTIVES To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS. DESIGN, SETTING, AND PARTICIPANTS The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment between January 1, 2015, and May 31, 2018. Data analysis was performed from January 1, 2015, to May 31, 2019. EXPOSURE IVT and/or EVT. MAIN OUTCOMES AND MEASURES Primary outcome was day 90 favorable outcome (modified Rankin Scale [mRs] 0-2, with 0 indicating no symptoms and 6 indicating death). Secondary end points included 1-year favorable outcome (mRs, 0-2), mortality, and symptomatic intracerebral hemorrhage. Other measures included the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), with pedNIHSS 0 indicating no symptoms, 1 to 4 corresponding to a minor stroke, 5 to 15 corresponding to a mild stroke, greater than 15 to 20: severe stroke, and the adult Alberta Stroke Program Early CT Score (ASPECTS), which provides segmental assessment of the vascular territory, with 1 point deducted from the initial score of 10 for every region involved (from 10 [no lesion] to 0 [maximum lesions]). RESULTS Overall, 68 children were included in 30 centers (IVT [n = 44]; EVT [n = 40]; 44 boys [64.7%]; median [IQR] age, 11 [4-16] years; anterior circulation involvement, 57 [83.8%]). Median (IQR) pedNIHSS score at admission was 13 (7-19), higher in the EVT group at 16 (IQR, 10-20) vs 9 (6-17) in the IVT only group (P < .01). Median time from stroke onset to imaging was higher in the EVT group at 3 hours and 7 minutes (IQR, 2 hours and 3 minutes to 6 hours and 24 minutes) vs 2 hours and 39 minutes (IQR, 1 hour and 51 minutes to 4 hours and 13 minutes) (P = .04). Median admission ASPECTS score was 8 (IQR, 6-9). The main stroke etiologies were cardioembolic (21 [30.9%]) and focal cerebral arteriopathy (17 [25.0%]). Median (IQR) time from stroke onset to IVT was 3 hours and 30 minutes (IQR, 2 hours and 33 minutes to 4 hours and 28 minutes). In the EVT group, the rate of postprocedure successful reperfusion (≥modified Treatment in Cerebral Infarction 2b) was 80.0% (32 of 40). Persistent proximal arterial stenosis was more frequent in focal cerebral arteriopathy (P < .01). Death occurred in 3 patients (4.4%). Median pedNIHSS reduction at 24 hours was 4 (IQR, 0-9) points. Intracerebral hemorrhage occurred in 4 patients and symptomatic intracerebral hemorrhage occurred in 1 patient, all in the EVT group. The median mRS was 2 (IQR, 0-3) at day 90 and 1 (IQR, 0-2) at 1 year, which was not significantly different between EVT and IVT only groups, although different in initial severity. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.
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Affiliation(s)
- Manoëlle Kossorotoff
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
- Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Inserm, Hôpital Necker-Enfants malades, Paris, France
| | - Basile Kerleroux
- Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France
- GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris Cité, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France
| | - Grégoire Boulouis
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
- Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France
- Neuroradiology, Tours University, CHRU Bretonneau, Tours, France
| | - Béatrice Husson
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
- Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Université de Paris-Saclay, Hôpital Bicêtre, le Kremlin-Bicêtre, France
| | - Kim Tran Dong
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
| | - François Eugene
- Neuroradiology, Rennes University, CHU de Rennes, Rennes, France
| | - Lena Damaj
- Pediatric Department, Rennes University, CHU de Rennes, Rennes, France
| | - Augustin Ozanne
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
- Department of Interventional Neuroradiology Neuro Brain Vascular Center, Assistance publique-Hôpitaux de Paris, Paris-Saclay University, Hôpital Bicêtre, le Kremlin-Bicêtre, France
| | - Céline Bellesme
- Pediatric Stroke Unit and Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Paris-Saclay University, Hôpital Bicêtre, le Kremlin-Bicêtre, France
| | - Anne Rolland
- Neurology Department, Nantes University, CHU de Nantes, Nantes, France
| | - Romain Bourcier
- Pediatric Department, Nantes University, CHU de Nantes, Nantes, France
| | | | - Gaultier Marnat
- Neuroradiology Department, Bordeaux University, CHU de Bordeaux, Bordeaux, France
| | - Jean-Philippe Neau
- Neurology Department. Poiters University, CHU de Poitiers, Poitiers, France
| | - Sylvie Joriot
- Pediatric Neurology Department, Lille University, CHU de Lille, Lille, France
| | - Alexandra Perez
- Pediatric Department, Strasbourg University, CHU de Strasbourg, Strasbourg, France
| | - Maud Guillen
- Neurology Department, Rennes University, CHU de Rennes, Rennes, France
| | | | - Frederique Audic
- Pediatric Neurology Department, Aix-Marseille University, CHU la Timone, Marseille, France
| | - Jean François Hak
- Neuroradiology, Aix-Marseille University, CHU la Timone, Marseille, France
| | - Christian Denier
- Pediatric Stroke Unit and Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Paris-Saclay University, Hôpital Bicêtre, le Kremlin-Bicêtre, France
| | - Olivier Naggara
- Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France
- Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Inserm, Hôpital Necker-Enfants malades, Paris, France
- GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris Cité, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France
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Scoville J, Joyce E, Harper J, Hunsaker J, Gren L, Porucznik C, Kestle JRW. A survey and analysis of pediatric stroke protocols. J Stroke Cerebrovasc Dis 2022; 31:106661. [PMID: 35896054 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/24/2022] [Accepted: 07/17/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives Despite their comparative rarity, about 10,000 ischemic strokes occur in children every year, and no standardized method of treatment exists. Protocols have been effective at increasing diagnosis accuracy and treatment efficacy in adults, but little has been done to evaluate such tools in children. A survey was developed to identify the proportion of pediatric hospitals that have stroke protocols and analyze the components used for diagnosis and treatment to identify consensus. Materials and methods Physicians at 50 pediatric hospitals that contributed to the Pediatric Hospital Inpatient Sample in specialties involved in the treatment of stroke (i.e, neurology, neurosurgery, radiology, pediatric intensive care, and emergency medicine) were invited in a purposive and referral manner to complete and 18-question survey. Consensus agreement was predefined as >75%. Results Of 264 surveys distributed, 93 (35%) were returned, accounting for 46 (92%) hospitals. Among the respondents, 76 (82%) reported the presence of a pediatric stroke protocol at their hospital. Consensus agreement was reached in 9 components, including the use of intravenous tissue plasminogen activator (90%) and mechanical thrombectomy (77%) as treatments for acute stroke. Consensus agreement was not reached in 10 components, including the use of prehospital (16%) and emergency department (59%) screening tools and a centralized contact method (57%). Conclusions Pediatric ischemic stroke is a potentially devastating disease that is potentially reversible if treated early. Most pediatric hospitals have developed stroke protocols to aid in diagnosis and treatment, but there is a lack of consensus on what the protocols should contain.
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Affiliation(s)
- Jonathan Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA; Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Evan Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA
| | - Jonathan Harper
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Joshua Hunsaker
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lisa Gren
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Christina Porucznik
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - John R W Kestle
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive, Salt Lake City, UT 84123, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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13
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Mastrangelo M, Giordo L, Ricciardi G, De Michele M, Toni D, Leuzzi V. Acute ischemic stroke in childhood: a comprehensive review. Eur J Pediatr 2022; 181:45-58. [PMID: 34327611 DOI: 10.1007/s00431-021-04212-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/10/2021] [Accepted: 07/15/2021] [Indexed: 12/27/2022]
Abstract
This review provides an updated analysis of the main aspects involving the diagnosis and the management of children with acute ischemic stroke. Acute ischemic stroke is an emergency of rare occurrence in children (rate of incidence of 1/3500 live birth in newborns and 1-2/100,000 per year during childhood with peaks of incidence during the perinatal period, under the age of 5 and in adolescence). The management of ischemic stroke in the paediatric age is often challenging because of pleomorphic age-dependent risk factors and aetiologies, high frequency of subtle or atypical clinical presentation, and lacking evidence-based data about acute recanalization therapies. Each pediatric tertiary centre should activate adequate institutional protocols for the optimization of diagnostic work-up and treatments.Conclusion: The implementation of institutional standard operating procedures, summarizing the steps for the selection of candidate for neuroimaging among the ones presenting with acute neurological symptoms, may contribute to shorten the times for thrombolysis and/or endovascular treatments and to improve the long-term outcome. What is Known: •Acute ischemic stroke has a higher incidence in newborns than in older children (1/3500 live birth versus 1-2/100,000 per year). •Randomized clinical trial assessing safety and efficacy of thrombolysis and/or endovascular treatment were never performed in children What is New: •Recent studies evidenced a low risk (2.1% of the cases) of intracranial haemorrhages in children treated with thrombolysis. •A faster access to neuroimaging and hyper-acute therapies was associated with the implementation of institutional protocols for the emergency management of pediatric stroke.
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14
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Hutchinson ML, Beslow LA, Shih EK, Licht DJ, Kimmel AC, Granath C, Ichord RN. Endovascular and thrombolytic treatment eligibility in childhood arterial ischemic stroke. Eur J Paediatr Neurol 2021; 34:99-104. [PMID: 34454335 DOI: 10.1016/j.ejpn.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/04/2021] [Accepted: 08/23/2021] [Indexed: 01/02/2023]
Abstract
AIM To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke treatment pathway in 2005. METHODS A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 - <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway. RESULTS Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5 h of time last seen well, 6 had PedNIHSS scores 6-24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6 h of time last seen well with a PedNIHSS score 6-24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6 h from time last seen well. CONCLUSIONS Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.
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15
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Visser MJ, Yang JYM, Calamante F, Kean M, Adamson CL, Sharma G, Anderson V, Campbell BCV, Mackay MT. Automated Perfusion-Diffusion Magnetic Resonance Imaging in Childhood Arterial Ischemic Stroke. Stroke 2021; 52:3296-3304. [PMID: 34404238 DOI: 10.1161/strokeaha.120.032822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Melissa J Visser
- Brain and Mind (M.J.V., V.A.), Murdoch Children's Research Institute, Parkville, Australia.,Melbourne School of Psychological Sciences (M.J.V., V.A.), University of Melbourne, Parkville, Australia
| | - Joseph Yuan-Mou Yang
- Neuroscience Research (J.Y.-M.Y., M.K., M.T.M.), Murdoch Children's Research Institute, Parkville, Australia.,Developmental Imaging (J.Y.-M.Y., C.L.A.), Murdoch Children's Research Institute, Parkville, Australia.,Department of Pediatrics (J.Y.-M.Y., V.A., M.T.M.), University of Melbourne, Parkville, Australia.,Neuroscience Advanced Clinical Imaging Service (NACIS), Department of Neurosurgery (J.Y.-M.Y.), Royal Children's Hospital, Parkville, Australia
| | - Fernando Calamante
- The University of Sydney, Sydney Imaging and School of Biomedical Engineering, Australia (F.C.)
| | - Michael Kean
- Neuroscience Research (J.Y.-M.Y., M.K., M.T.M.), Murdoch Children's Research Institute, Parkville, Australia
| | - Christopher L Adamson
- Developmental Imaging (J.Y.-M.Y., C.L.A.), Murdoch Children's Research Institute, Parkville, Australia.,Department of Electrical and Electronic Engineering (C.L.A.), University of Melbourne, Parkville, Australia
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (G.S., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Vicki Anderson
- Brain and Mind (M.J.V., V.A.), Murdoch Children's Research Institute, Parkville, Australia.,Melbourne School of Psychological Sciences (M.J.V., V.A.), University of Melbourne, Parkville, Australia.,Department of Pediatrics (J.Y.-M.Y., V.A., M.T.M.), University of Melbourne, Parkville, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (G.S., B.C.V.C.), University of Melbourne, Parkville, Australia.,Florey Institute of Neurosciences and Mental Health, Parkville, Australia (B.C.V.C.)
| | - Mark T Mackay
- Neuroscience Research (J.Y.-M.Y., M.K., M.T.M.), Murdoch Children's Research Institute, Parkville, Australia.,Department of Pediatrics (J.Y.-M.Y., V.A., M.T.M.), University of Melbourne, Parkville, Australia.,Department of Neurology (M.T.M.), Royal Children's Hospital, Parkville, Australia
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16
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Sporns PB, Fullerton HJ, Lee S, Kirton A, Wildgruber M. Current treatment for childhood arterial ischaemic stroke. Lancet Child Adolesc Health 2021; 5:825-836. [PMID: 34331864 DOI: 10.1016/s2352-4642(21)00167-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Paediatric arterial ischaemic stroke is an important cause of neurological morbidity in children, with consequences including motor disorders, intellectual impairment, and epilepsy. The causes of paediatric arterial ischaemic stroke are unique compared with those associated with stroke in adulthood. The past decade has seen substantial advances in paediatric stroke research and clinical care, but many unanswered questions and controversies remain. Shortage of prospective evidence for the use of recanalisation therapies in patients with paediatric stroke has resulted in little standardisation of disease management. Substantial time delays in diagnosis and treatment continue to challenge best possible care. In this Review, we highlight on some of the most pressing and productive aspects of research in the treatment of arterial ischaemic stroke in children, including epidemiology and cause, rehabilitation, secondary stroke prevention, and treatment updates focusing on advances in hyperacute therapies such as intravenous thrombolysis, mechanical thrombectomy, and critical care. Finally, we provide a future perspective for improving outcomes and quality of life for affected children and their families.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Weill Institute of Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam Kirton
- Department of Pediatrics and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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17
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Hollist M, Au K, Morgan L, Shetty PA, Rane R, Hollist A, Amaniampong A, Kirmani BF. Pediatric Stroke: Overview and Recent Updates. Aging Dis 2021; 12:1043-1055. [PMID: 34221548 PMCID: PMC8219494 DOI: 10.14336/ad.2021.0219] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/24/2022] Open
Abstract
Stroke can occur at any age or stage in life. Although it is commonly thought of as a disease amongst the elderly, it is important to highlight the fact that it also affects infants and children. In both populations, strokes have a high rate of morbidity and mortality. Arguably, it is more detrimental in the pediatric population given the occurrence at a younger age and therefore, a longer duration of disability, potentially over the entire lifespan. The high rate of morbidity and mortality in pediatrics is attributed to significant delays in diagnosis, as well as misdiagnosis. Acute stroke management is time dependent. Patients who receive acute treatment with either intravenous (IV) tissue plasminogen activator (tPA) or mechanical thrombectomy, have improved mortality and functional outcomes. Additionally, the earlier treatment is initiated, the higher the likelihood of preserving penumbra, restoring cerebral blood flow and potentially reversing symptoms, thereby limiting disability. Prompt identification is essential as it leads to improved patient care in such a narrow therapeutic window. It enhances the care received during hospitalization and reduces the risk of early stroke recurrence. Despite limited data and lack of large randomized clinical trials in pediatrics, both IV tPA and mechanical thrombectomy have been successfully used. Bridging the gap of acute stroke management in the pediatric population is an essential part of minimizing adverse outcomes. In this review, we discuss the epidemiology of pediatric stroke, the diverse etiologies, presentation as well as both acute and preventative management.
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Affiliation(s)
- Mary Hollist
- 1Memorial Healthcare Institute for Neurosciences, Owosso MI, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Larry Morgan
- 3Bronson Neuroscience Center, Kalamazoo, MI, USA
| | - Padmashri A Shetty
- 4Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Riddhi Rane
- 7Texas A&M University College of Medicine, College Station, TX, USA
| | | | | | - Batool F Kirmani
- 7Texas A&M University College of Medicine, College Station, TX, USA.,8Endovascular Therapy & Interventional Stroke Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1213-1221. [PMID: 33719517 DOI: 10.1161/strokeaha.120.032009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke. METHODS This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes. RESULTS Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge. CONCLUSIONS Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Aurora (M.B.)
| | - Dwight Barry
- Clinical Analytics (D.B.), Seattle Children's Hospital
| | - Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine in St Louis (A.P.K.)
| | - Danial Hallam
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle (D.H.)
| | - Michael Abraham
- Departments of Neurology and Interventional Radiology, University of Kansas Medical Center (M.A.)
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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21
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Abstract
No controlled pharmacological studies are available in the field of pediatric stroke, except for sickle cell disease. Therefore, while pharmacological and mechanical recanalization treatments have repeatedly shown clinical benefit in adults with arterial ischemic stroke, pediatric strokologists still cannot base their therapeutic management (including hyperacute strategies) on high-level evidence. Once again, pediatricians face the same dichotomic choice: adapting adult procedures now versus waiting-for a long time-for the corresponding pediatric trials. One way out is building a compromise based on observational studies with large, longitudinal, comprehensive, real-life, and multisource dataset. Two recent high-quality observational studies have delivered promising conclusions on recanalization treatments in pediatric arterial ischemic stroke. TIPSTER (Thrombolysis in Pediatric Stroke Extended Results) showed that the risk of severe intracranial hemorrhage after intravenous thrombolysis is low; the Save Childs Study reported encouraging data about pediatric thrombectomy. Beyond the conclusion of a satisfactory global safety profile, a thorough analysis of the methods, populations, results, and therapeutic complications of these studies helps us to refine indications/contraindications and highlights the safeguards we need to rely on when discussing thrombolysis and thrombectomy in children. In conclusion, pediatric strokologists should not refrain from using clot lysis/retrieval tools in selected children with arterial ischemic stroke. But the implementation of hyperacute care is only feasible if the right candidate is identified through the sharing of common adult/pediatric protocols and ward collaboration, formalized well before the child's arrival. These anticipated protocols should never undervalue contraindications from adult guidelines and must involve the necessary pediatric expertise when facing specific causes of stroke, such as focal cerebral arteriopathy of childhood.
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Affiliation(s)
- Stéphane Chabrier
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Inserm, Université Saint-Étienne, UMR1059, Saint-Étienne, France (S.C.)
| | - Augustin Ozanne
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Department of Interventional Neuroradiology Neuro Brain Vascular Center, Assistance publique-Hôpitaux de Paris, Paris-Saclay University, Hôpital Bicêtre, le Kremlin-Bicêtre, France (A.O.)
| | - Olivier Naggara
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France (O.N., G.B.).,GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France (O.N., G.B.)
| | - Grégoire Boulouis
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France (O.N., G.B.).,GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France (O.N., G.B.)
| | - Béatrice Husson
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Université de Paris-Saclay, Hôpital Bicêtre, le Kremlin-Bicêtre, France (B.H.)
| | - Manoëlle Kossorotoff
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Inserm, Hôpital Necker-Enfants malades, Paris, France (M.K.)
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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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23
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Sporns PB, Sträter R, Minnerup J, Wiendl H, Hanning U, Chapot R, Henkes H, Henkes E, Grams A, Dorn F, Nikoubashman O, Wiesmann M, Bier G, Weber A, Broocks G, Fiehler J, Brehm A, Psychogios M, Kaiser D, Yilmaz U, Morotti A, Marik W, Nolz R, Jensen-Kondering U, Schmitz B, Schob S, Beuing O, Götz F, Trenkler J, Turowski B, Möhlenbruch M, Wendl C, Schramm P, Musolino P, Lee S, Schlamann M, Radbruch A, Rübsamen N, Karch A, Heindel W, Wildgruber M, Kemmling A. Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study. JAMA Neurol 2020; 77:25-34. [PMID: 31609380 DOI: 10.1001/jamaneurol.2019.3403] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Randomized clinical trials have shown the efficacy of thrombectomy of large intracranial vessel occlusions in adults; however, any association of therapy with clinical outcomes in children is unknown. Objective To evaluate the use of endovascular recanalization in pediatric patients with arterial ischemic stroke. Design, Setting, and Participants This retrospective, multicenter cohort study, conducted from January 1, 2000, to December 31, 2018, analyzed the databases from 27 stroke centers in Europe and the United States. Included were all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization. Median follow-up time was 16 months. Exposures Endovascular recanalization. Main Outcomes and Measures The decrease of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission to day 7 was the primary outcome (score range: 0 [no deficit] to 34 [maximum deficit]). Secondary clinical outcomes included the modified Rankin scale (mRS) (score range: 0 [no deficit] to 6 [death]) at 6 and 24 months and rate of complications. Results Seventy-three children from 27 participating stroke centers were included. Median age was 11.3 years (interquartile range [IQR], 7.0-15.0); 37 patients (51%) were boys, and 36 patients (49%) were girls. Sixty-three children (86%) received treatment for anterior circulation occlusion and 10 patients (14%) received treatment for posterior circulation occlusion; 16 patients (22%) received concomitant intravenous thrombolysis. Neurologic outcome improved from a median PedNIHSS score of 14.0 (IQR, 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7. Median mRS score was 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months. One patient (1%) developed a postinterventional bleeding complication and 4 patients (5%) developed transient peri-interventional vasospasm. The proportion of symptomatic intracerebral hemorrhage events in the HERMES meta-analysis of trials with adults was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40). Conclusions and Relevance The results of this study suggest that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults; most of the treated children had favorable neurologic outcomes. This study may support clinicians' practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.
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Affiliation(s)
- Peter B Sporns
- Institute of Clinical Radiology, University Hospital of Muenster, Muenster, Germany
| | - Ronald Sträter
- Department of Pediatrics, University Hospital of Muenster, Muenster, Germany
| | - Jens Minnerup
- Department of Neurology, University Hospital of Muenster, Muenster, Germany
| | - Heinz Wiendl
- Department of Neurology, University Hospital of Muenster, Muenster, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - René Chapot
- Department of Neuroradiology, Alfried-Krupp Hospital, Essen, Germany
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Elina Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Dorn
- Department for Diagnostic and Interventional Neuroradiology, University of Munich, Campus Grosshadern, Munich, Germany
| | | | - Martin Wiesmann
- Department of Neuroradiology, Aachen University, Aachen, Germany
| | - Georg Bier
- Institute of Clinical Radiology, University Hospital of Muenster, Muenster, Germany.,Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Anushe Weber
- Department of Radiology and Neuroradiology, Bochum, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alex Brehm
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Marios Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University Hospital, Homburg, Germany
| | - Andrea Morotti
- Department of Neurology and Neurorehabilitation, Mondino Foundation, Pavia, Italy
| | - Wolfgang Marik
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Richard Nolz
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Bernd Schmitz
- Section of Neuroradiology, University of Ulm, Guenzburg, Germany
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Oliver Beuing
- Department of Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Friedrich Götz
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Johannes Trenkler
- Department of Neuroradiology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Bernd Turowski
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology at Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Hospital of Luebeck, Luebeck, Germany
| | - Patricia Musolino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Stanford, California
| | - Marc Schlamann
- Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Alexander Radbruch
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
| | - Nicole Rübsamen
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - André Karch
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Walter Heindel
- Institute of Clinical Radiology, University Hospital of Muenster, Muenster, Germany
| | - Moritz Wildgruber
- Institute of Clinical Radiology, University Hospital of Muenster, Muenster, Germany
| | - André Kemmling
- Department of Neurology, University Hospital of Muenster, Muenster, Germany
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24
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Catenaccio E, Riggs BJ, Sun LR, Urrutia VC, Johnson B, Torriente AG, Felling RJ. Performance of a Pediatric Stroke Alert Team Within a Comprehensive Stroke Center. J Child Neurol 2020; 35:571-577. [PMID: 32354255 DOI: 10.1177/0883073820920111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Childhood stroke is rare, and diagnosis is frequently delayed. The use of pediatric stroke teams has the potential to decrease time to neurology evaluation and imaging, hastening appropriate diagnosis and treatment for acute neurologic presentations in children. METHODS We performed a retrospective analysis of our institutional pediatric stroke or "brain attack" team (pedsBAT) activations from October 2014 to July 2017. Clinical characteristics and timing parameters were compared between pedsBAT activations in the inpatient vs emergency department (ED) / outpatient settings as well as between pediatric and adult BAT activations in the same time period. RESULTS We identified 120 pedsBAT activations (75% in the ED/outpatient setting) during the study time period. Inpatient pedsBAT activations were more likely than outpatient activations to have heart disease as a risk factor for ischemic stroke and presented more frequently with altered mental status, but there were no differences in the proportion of cerebrovascular diagnoses or timing parameters between the 2 groups. When compared with adult BAT activations, outpatient pedsBAT activations had a longer time from symptom discovery to arrival at the ED, and inpatient pedsBAT activations had longer time from symptom discovery to BAT activation. CONCLUSIONS Compared with adults, the interval leading up to stroke team activation was longer in children, suggesting delays in symptom recognition. Future interventions should be aimed at reducing these delays in presentation to care and stroke alert activation in pediatric patients.
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Affiliation(s)
- Eva Catenaccio
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Becky J Riggs
- Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Comprehensive Stroke Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Comprehensive Stroke Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brenda Johnson
- Johns Hopkins Comprehensive Stroke Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Comprehensive Stroke Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Abstract
Background Several randomized trials have shown the efficacy of thrombectomy for large intracranial vessel occlusions in adults. However, the safety and efficacy of thrombectomy in children are unknown. We aimed to investigate the feasibility and outcome of thrombectomy in pediatric patients. Methods and Results We performed a retrospective analysis of all children (<18 years of age) who presented with large-vessel occlusion and were treated with mechanical thrombectomy at 3 German tertiary-care stroke centers. Interventional results and clinical outcomes were assessed using the Pediatric National Institutes of Health Stroke Scale at 24 hours and on day 7 after thrombectomy as well as after 3 months (modified Rankin Scale). After screening of local registries for all performed thrombectomies, 12 children were included. Median Pediatric National Institutes of Health Stroke Scale score on admission was 12.5 (interquartile range 8.0-21.5). Angiographic outcomes for thrombectomy were good in all patients (6×modified Treatment in Cerebral Infarction Score 3, 6×modified Treatment in Cerebral Infarction Score 2b). Moreover, most patients showed an improvement of neurological outcome after thrombectomy with a median Pediatric National Institutes of Health Stroke Scale of 3.5 (interquartile range 1-8) at day 7 and a modified Rankin Scale of 1.0 (interquartile range 0-2.0) at 3 months. No major periprocedural complications were observed. Conclusions In our retrospective study thrombectomy was safe in childhood stroke, and treated children had good neurological outcomes.
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Affiliation(s)
- Peter B Sporns
- 1 Institute of Clinical Radiology University Hospital of Muenster Germany
| | - André Kemmling
- 1 Institute of Clinical Radiology University Hospital of Muenster Germany.,2 Department of Neuroradiology University Hospital of Luebeck Germany
| | - Uta Hanning
- 3 Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jens Minnerup
- 4 Department of Neurology University of Muenster Germany
| | - Ronald Sträter
- 5 Department of Pediatrics University of Muenster Germany
| | - Thomas Niederstadt
- 1 Institute of Clinical Radiology University Hospital of Muenster Germany
| | - Walter Heindel
- 1 Institute of Clinical Radiology University Hospital of Muenster Germany
| | - Moritz Wildgruber
- 1 Institute of Clinical Radiology University Hospital of Muenster Germany
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Wharton JD, Barry MM, Lee CA, Massey K, Ladner TR, Jordan LC. Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years. J Pediatr 2020; 220:214-220.e1. [PMID: 32147216 DOI: 10.1016/j.jpeds.2020.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the implementation and utilization of a pediatric acute stroke protocol over a 7-year period, hypothesizing improvements in protocol implementation and increased protocol use over time. STUDY DESIGN Clinical and demographic data for this retrospective observational study from 2011 through 2018 were obtained from a quality improvement database and medical records of children for whom the acute stroke protocol was activated. The initial 43 months of the protocol (period 1) were compared with the subsequent 43 months (period 2). RESULTS Over the 7-year period, a total of 385 stroke alerts were activated, in 150 children (39%) in period 1 and 235 (61%) in period 2, representing a 56% increase in protocol activation. Stroke was the final diagnosis in 80 children overall (21%), including 38 (25%) in period 1 and 42 (19%) in period 2 (P = .078). The combined frequency of diagnosed stroke, transient ischemic attack (TIA), and other neurologic emergencies remained stable across the 2 time periods at 39% and 37%, respectively (P = .745). Pediatric National Institutes of Health Stroke Scale (PedNIHSS) documentation increased from 42% in period 1 to 82% in period 2 (P < .001). Magnetic resonance imaging (MRI) was the first neuroimaging study for 68% of the children in period 1 vs 78% in period 2 (P = .038). All children with acute stroke received immediate supportive care. CONCLUSIONS Pediatric stroke protocol implementation improved over time with increased use of the PedNIHSS and use of MRI as the first imaging study. However, with increased utilization, the frequency of confirmed strokes and other neurologic emergencies remained stable. The frequency of stroke and other neurologic emergencies in these children affirms the importance of implementing and maintaining a pediatric acute stroke protocol.
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Affiliation(s)
- Jessica D Wharton
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Megan M Barry
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Neurology, University of Colorado, Aurora, CO
| | - Chelsea A Lee
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Travis R Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN.
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27
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Hanes I, Orr S, Davila J, Kirton A, Sell E. Thrombolysis in a Child with Acute Arterial Ischemic Stroke without Large Vessel Occlusion. Can J Neurol Sci 2020; 47:275-277. [PMID: 31915080 PMCID: PMC7062547 DOI: 10.1017/cjn.2020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Malik P, Patel UK, Kaul S, Singla R, Kavi T, Arumaithurai K, Jani VB. Risk factors and outcomes of intravenous tissue plasminogen activator and endovascular thrombectomy utilization amongst pediatrics acute ischemic stroke. Int J Stroke 2020; 16:172-183. [PMID: 32009581 DOI: 10.1177/1747493020904915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population. AIM We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations. METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003-2014) in pediatric (1-21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations. RESULTS In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003-2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups (p < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50-147.29, p = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92-40.76, p = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16-49.31, p = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group. CONCLUSION We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.
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Affiliation(s)
- Preeti Malik
- Department of Public Health, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Urvish K Patel
- Department of Neurology & Public Health, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Surabhi Kaul
- Department of Pediatric and Adolescent Care, MercyOne North Iowa Medical Center, Mason City, IA, USA
| | - Ramit Singla
- Department of Pediatric Neurology, 2956Detroit Medical Center, Detroit, MI, USA
| | - Tapan Kavi
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Vishal B Jani
- Department of Neurology, 12282Creighton University School of Medicine, Omaha, NE, USA
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30
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Amlie-Lefond C, Shaw DW, Cooper A, Wainwright MS, Kirton A, Felling RJ, Abraham MG, Mackay MT, Dowling MM, Torres M, Rivkin MJ, Grabowski EF, Lee S, Kurz JE, McMillan HJ, Barry D, Lee-Eng J, Ichord RN. Risk of Intracranial Hemorrhage Following Intravenous tPA (Tissue-Type Plasminogen Activator) for Acute Stroke Is Low in Children. Stroke 2020; 51:542-548. [DOI: 10.1161/strokeaha.119.027225] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data regarding the safety and efficacy of intravenous tPA (tissue-type plasminogen activator) in childhood acute arterial ischemic stroke are inadequate. The TIPS trial (Thrombolysis in Pediatric Stroke; National Institutes of Health grant R01NS065848)—a prospective safety and dose-finding trial of intravenous tPA in acute childhood stroke—was closed for lack of accrual. TIPS sites have subsequently treated children with acute stroke in accordance with established institutional protocols supporting data collection on outcomes.
Methods—
Data on children treated with intravenous tPA for neuroimaging-confirmed arterial ischemic stroke were collected retrospectively from 16 former TIPS sites to establish preliminary safety data. Participating sites were required to report all children who were treated with intravenous tPA to minimize reporting bias. Symptomatic intracranial hemorrhage (SICH) was defined as ECASS (European Cooperative Acute Stroke Study) II parenchymal hematoma type 2 or any intracranial hemorrhage associated with neurological deterioration within 36 following tPA administration. A Bayesian beta-binomial model for risk of SICH following intravenous tPA was fit using a prior distribution based on the risk level in young adults (1.7%); to test for robustness, the model was also fit with uninformative and conservative priors.
Results—
Twenty-six children (age range, 1.1–17 years; median, 14 years; 12 boys) with stroke and a median pediatric National Institutes of Health Stroke Scale score of 14 were treated with intravenous tPA within 2 to 4.5 hours (median, 3.0 hours) after stroke onset. No patient had SICH. Two children developed epistaxis.
Conclusions—
The estimated risk of SICH after tPA in children is 2.1% (95% highest posterior density interval, 0.0%–6.7%; mode, 0.9%). Regardless of prior assumption, there is at least a 98% chance that the risk is <15% and at least a 93% chance that the risk is <10%. These results suggest that the overall risk of SICH after intravenous tPA in children with acute arterial ischemic stroke, when given within 4.5 hours after symptom onset, is low.
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Affiliation(s)
- Catherine Amlie-Lefond
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Dennis W.W. Shaw
- Department of Radiology (D.W.W.S.), Seattle Children’s Hospital, WA
| | - Andrew Cooper
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Mark S. Wainwright
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Adam Kirton
- Department of Neurology, Alberta Children’s Hospital, Calgary, Canada (A.K.)
| | - Ryan J. Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.J.F.)
| | | | - Mark T. Mackay
- Department of Neurology, The Royal Children’s Hospital, Melbourne, VIC, Australia (M.T.M.)
| | - Michael M. Dowling
- Department of Neurology, Children’s Medical Center at Dallas, TX (M.M.D.)
| | - Marcela Torres
- Department of Hematology, Cook Children’s Medical Center, Fort Worth, TX (M.T.)
| | | | - Eric F. Grabowski
- Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston (E.F.G.)
| | - Sarah Lee
- Department of Neurology, Stanford University, Palo Alto, CA (S.L.)
| | - Jonathan E. Kurz
- Department of Neurology, Ann & Robert H Lurie Children’s Hospital of Chicago, IL (J.E.K.)
| | - Hugh J. McMillan
- Department of Neurology, Children’s Hospital of Eastern Ontario, Ottawa, Canada (H.J.M.)
| | - Dwight Barry
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Jacqueline Lee-Eng
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Rebecca N. Ichord
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kossorotoff M, Chabrier S, Tran Dong K, Nguyen The Tich S, Dinomais M. Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities. Rev Neurol (Paris) 2020; 176:20-9. [DOI: 10.1016/j.neurol.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Rambaud T, Legris N, Bejot Y, Bellesme C, Lapergue B, Jouvent E, Pico F, Smadja D, Zuber M, Crozier S, Lamy C, Spelle L, Tuppin P, Kossorotoff M, Denier C. Acute ischemic stroke in adolescents. Neurology 2019; 94:e158-e169. [PMID: 31831601 DOI: 10.1212/wnl.0000000000008783] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/30/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Adolescence represents a transition period between childhood and adulthood, and only limited information exists about stroke characteristics in this population. Our aim was to describe the clinical and neuroradiologic features, etiologies, initial management, and outcome of ischemic stroke in adolescents. METHODS This retrospective cohort study evaluated all consecutive patients 10 to 18 years with a first-ever ischemic stroke hospitalized between 2007 and 2017 in 10 French academic centers representing a population of ≈10 million. Extracted data from the national database served as validation. RESULTS A total of 60 patients were included (53% male, median age 15.2 years). Diagnosis at first medical contact was misevaluated in 36%, more frequently in posterior than anterior circulation strokes (55% vs 20% respectively, odds ratio 4.8, 95% confidence interval 1.41-16.40, p = 0.01). Recanalization treatment rate was high (n = 19, 32%): IV thrombolysis (17%), endovascular therapy (11.7%), or both IV and intra-arterial thrombolysis (3.3%); safety was good (only 1 asymptomatic hemorrhagic transformation). Despite thorough etiologic workup, 50% of strokes remained cryptogenic. The most common determined etiologies were cardioembolism (15%), vasculitis and autoimmune disorders (12%, occurring exclusively in female patients), and arterial dissections (10%, exclusively in male patients). Recurrent ischemic cerebrovascular events occurred in 12% (median follow-up 19 months). Recurrence rate was 50% in patients with identified vasculopathy but 0% after cryptogenic stroke. Functional outcome was favorable (Rankin Scale score 0-2 at day 90) in 80% of cases. CONCLUSIONS Ischemic strokes in adolescents harbor both pediatric and adult features, emphasizing the need for multidisciplinary collaboration in their management. Recanalization treatments appear feasible and safe.
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Affiliation(s)
- Thomas Rambaud
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Nicolas Legris
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Yannick Bejot
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Céline Bellesme
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Bertrand Lapergue
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Eric Jouvent
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Fernando Pico
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Didier Smadja
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Mathieu Zuber
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Sophie Crozier
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Catherine Lamy
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Laurent Spelle
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Philippe Tuppin
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Manoelle Kossorotoff
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France
| | - Christian Denier
- From the Stroke Units and Department of Neurology (T.R., N.L., C.D.), Hôpital Bicêtre, Le Kremlin Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris Saclay University; Department of Neurology (Y.B.), University Région Bourgogne, Hôpital de Dijon; Pediatric Neurology Unit (C.B.), Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; Stroke Units and Department of Neurology (B.L.), Hôpital Foch, Suresnes; Department of Neurology (E.J.), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (F.P.), Hôpital Andre Mignot, Versailles; Department of Neurology (D.S.), Hôpital Sud Francilien, Evry; Department of Neurology (M.Z.), Hôpital Saint Joseph, Paris; Department of Neurology (S.C.), Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Neurology (C.L.), Hôpital Sainte Anne, Paris; Interventional Neuroradiology (L.S.), NEURI Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre; French National Health Insurance (P.T.); and Pediatric Neurology Unit (M.K.), Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, France.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Boulouis G, Blauwblomme T, Hak JF, Benichi S, Kirton A, Meyer P, Chevignard M, Tournier-Lasserve E, Mackay MT, Chabrier S, Cordonnier C, Kossorotoff M, Naggara O. Nontraumatic Pediatric Intracerebral Hemorrhage. Stroke 2019; 50:3654-3661. [DOI: 10.1161/strokeaha.119.025783] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Gregoire Boulouis
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Jean François Hak
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
- Neuroimaging Department, CHRU La Timone, Marseille, France (J.F.H.)
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, AB, Canada (A.K.)
- Pediatric Neuro ICU (A.K.)
| | | | - Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint-Maurice Hospitals (M.C.)
| | - Elisabeth Tournier-Lasserve
- Genetics of Neurovascular disorders, AP-HP, Hôpital Lariboisière and Université de Paris, NeuroDiderot, Inserm, F-75010 (E.T.-L.)
| | - Mark T. Mackay
- Neurology Department, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, and Department of Paediatrics, University of Melbourne, Australia (M.T.M.)
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Center for Pediatic Stroke, F-42055 Saint-Étienne, France (S.C.)
| | - Charlotte Cordonnier
- Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Neurology Department, France (C.C.)
| | - Manoëlle Kossorotoff
- Department of Pediatric Neurology, French Center for Pediatic Stroke, NEM (M.K.)
| | - Olivier Naggara
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
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Mackay MT, Churilov L, Moon A, McKenzie I, Donnan GA, Monagle P, Li Q, Babl FE. Identification of barriers and enablers to rapid diagnosis along the paediatric stroke chain of recovery using Value-Focused Process Engineering. Health Syst (Basingstoke) 2019; 10:73-88. [PMID: 33758658 DOI: 10.1080/20476965.2019.1664941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Coordinated systems of care are required to improve access to reperfusion therapies in paediatric stroke. A conceptual model was developed to map the process-of-care from symptom onset to confirmation of diagnosis. Value-Focused Process Engineering with event-driven process modelling was used to identify barriers and enablers to timely and accurate paediatric stroke diagnosis. Stakeholder interviews were conducted to inform model design, development, demonstration and validation. Barriers included: (i) ambulance dispatcher failure to allocate high-priority response, (ii) childrens' exclusion from paramedic clinical practice guidelines, (ii) non-allocation of high triage category on hospital arrival, (iii) absence of emergency department guidelines for focal neurological deficits, and (iv) computed tomography as the first imaging investigation. Enablers included: (i) public awareness programs, (ii) childrens' inclusion in prehospital emergency stroke algorithms, (iii) re-organisation of health services, with primary paediatric stroke centres, (iv) implementation of triage and neuroimaging decision support tools, and (iv) rapid stroke MRI imaging protocols.
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Affiliation(s)
- Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Parkville, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Parkville, Australia.,Statistics and Decision Analysis Academic Platform, Florey Institute of Neurosciences and Mental Health, Parkville, Australia.,Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, Florey Institute of Neurosciences and Mental Health, Parkville, Australia.,Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia.,School of Mathematical and Geospatial Sciences, RMIT University, Melbourne, Australia
| | - Anna Moon
- Emergency Department, Royal Children's Hospital, Parkville, Australia
| | - Ian McKenzie
- Department of Medical Imaging, Royal Children's Hospital, Parkville, Australia
| | - Geoffrey A Donnan
- Statistics and Decision Analysis Academic Platform, Florey Institute of Neurosciences and Mental Health, Parkville, Australia.,Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia
| | - Paul Monagle
- Clinical Sciences Theme, Murdoch Children's Research Institute, Parkville, Australia.,Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia.,Department of Anaesthetics, Royal Children's Hospital, Parkville, Australia
| | - Qi Li
- Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia.,School of Mathematical and Geospatial Sciences, RMIT University, Melbourne, Australia
| | - Franz E Babl
- Clinical Sciences Theme, Murdoch Children's Research Institute, Parkville, Australia.,Departments of Paediatrics and Medicine, University of Melbourne, Parkville, Australia.,Department of Haematology, Royal Children's Hospital, Parkville, Australia
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Abstract
Background and Purpose—
Literature on the clinical manifestation and neuroradiological findings in pediatric patients with posterior circulation arterial ischemic stroke is scarce. This study aims to describe epidemiological features, clinical characteristics, and neuroimaging data on pediatric posterior circulation arterial ischemic stroke in Switzerland using the population-based Swiss Neuropediatric Stroke Registry.
Methods—
Children aged from 1 month to 16 years presenting with an isolated posterior circulation arterial ischemic stroke between 2000 and 2016 were included. Epidemiology, clinical manifestation, stroke cause, and neuroradiological features were summarized using descriptive statistics. Stroke severity was assessed using the pediatric National Institutes of Health Stroke Scale. Correlation analysis was performed using the Spearman correlation coefficient.
Results—
Forty-three children with posterior circulation arterial ischemic stroke were included (27 boys [62.8%], median age 7.9 years, interquartile range, 5 to 11.7 years). The incidence of posterior circulation arterial ischemic stroke is Switzerland was 0.183/100 000 and represented 16% of all childhood arterial ischemic strokes. Most patients presented with nonspecific neurological complaints, such as headache (58.1%) and nausea/vomiting (46.5%). The most frequent clinical manifestations were ataxia (58.1%) and motor/sensory hemisyndrome (53.5%/51.2%). Unilateral focal cerebral arteriopathy was the most common cause (11 children, 25.6%). Most infarcts were located in the cerebellum (46.5%) and thalamus (39.5%). A shorter diagnostic delay correlated with more severe stroke symptoms at presentation (rho= −0.365,
P
=0.016).
Conclusions—
Pediatric posterior circulation arterial ischemic stroke was caused by focal cerebral arteriopathy in one quarter of the patients in our cohort. The frequently reported nonspecific clinical symptoms, especially when associated with mild neurological findings, risk delaying the diagnosis of stroke. A high index of suspicion and increased awareness are required for timely diagnosis and treatment initiation.
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Affiliation(s)
- Mirjam Fink
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Nedelina Slavova
- Department of Neuroradiology, Bern University Hospital, University of Bern, Switzerland (N.S.)
| | - Sebastian Grunt
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Eveline Perret
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maria Regényi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Maja Steinlin
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
| | - Sandra Bigi
- From the Department of Pediatrics, Division of Child Neurology, University Children's Hospital Bern, University of Bern, Switzerland (M.F., S.G., E. P., M.R., M.S., S.B.)
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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40
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Affiliation(s)
- Philip Overby
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Matthew Kapklein
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Ronald I Jacobson
- Department of Neurology and.,Department of Pediatrics, New York Medical College, Valhalla, NY
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41
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Futch HS, Corliss BM, Polifka AJ, Hoh BL, Fox WC. Solitaire Stent Retriever Mechanical Thrombectomy in a 6-Month-Old Patient with Acute Occlusion of the Internal Carotid Artery Terminus: Case Report. World Neurosurg 2019; 126:631-7. [DOI: 10.1016/j.wneu.2019.03.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/23/2022]
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Sun LR, Felling RJ, Pearl MS. Endovascular mechanical thrombectomy for acute stroke in young children. J Neurointerv Surg 2019; 11:554-8. [DOI: 10.1136/neurintsurg-2018-014540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 11/03/2022]
Abstract
BackgroundMechanical thrombectomy has emerged as a standard of care for acute stroke from large vessel occlusion in adults but remains controversial in children. Cerebral vessels are nearly adult size by 5 years of age but the technical feasibility of achieving recanalization in younger and smaller children with current endovascular tools remains unclear.ObjectiveTo systematically review the literature on mechanical thrombectomy for stroke in children less than 5 years of age.ResultsMechanical thrombectomy for acute stroke has been reported in 11 children under the age of 5 years (range 9 months to 4 years). The mean time from symptom onset to groin puncture was 12 hours (range 4–50 hours). Complete recanalization was achieved in 7/12 (58%) vessels attempted, and partial recanalization in 4/12 (33%). Two procedure related complications were reported, with small vessel size felt to be contributory to basilar vasospasm in one case. Favorable neurological outcomes were reported in 7 cases (64%).ConclusionsOur review of the literature demonstrates that mechanical thrombectomy for acute ischemic stroke may be feasible in carefully selected infants and young children less than 5 years of age using currently available devices. Efficacy in promoting better neurologic outcomes remains unproven, and other questions persist, including whether complications such as vasospasm occur more frequently in young children compared with adults. Further study is needed to determine the safety and efficacy of pediatric mechanical thrombectomy. These data suggest that young children should not be excluded from future studies or clinical treatment on the basis of age alone.
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Affiliation(s)
- Laura L. Lehman
- From the Department of Neurology, Boston Children’s Hospital, Harvard Medical School, MA (L.L.L.)
| | - Lauren A. Beslow
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (L.A.B.)
| | - Maja Steinlin
- Division of Paediatric Neurology, University Children’s Hospital Bern, University of Bern, Switzerland (M.S.)
| | - Manoëlle Kossorotoff
- French Center for Pediatric Stroke, Pediatric Neurology, APHP University Hospital Necker-Enfants Malades, Paris, France (M.K.)
| | - Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Murdoch Children’s Research Institute, University of Melbourne, Parkville, Australia (M.T.M.)
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Abstract
This review will discuss important developments in childhood arterial ischemic stroke over the past decade, focusing on improved understanding of the causes, consequences, and targets for intervention. Risk factors for childhood arterial ischemic stroke are different to adults. Infections, particularly herpes group viruses, are important precipitants for stroke. Non-atherosclerotic arteriopathies are the most common cause of childhood arterial ischemic stroke and an important predictor of recurrent events. Recent advances include the identification of serum biomarkers for inflammation and endothelial injury, and imaging biomarkers to monitor for vascular progression. Multicenter trials of immunotherapies in focal cerebral arteriopathies are currently in development. Recognition of clinical and radiological phenotypic patterns has facilitated the discovery of multisystem disorders associated with arterial ischemic stroke including ACTA2 arteriopathy and adenosine deaminase 2 deficiency. Identification of these Mendelian disorders provide insights into genetic mechanisms of disease and have implications for medical and surgical management. In contrast to adults, there are long diagnostic delays in childhood arterial ischemic stroke. Refinement of pediatric Code Stroke protocols and clinical decision support tools are essential to improve diagnostic certainty and improve access to reperfusion therapies. Children do not recover better than adults following arterial ischemic stroke, with more than half of survivors having long-term impairments. The physical, cognitive, and behavioral consequences of childhood arterial ischemic stroke are increasingly reported but further research is required to understand their impact on participation, quality of life, psychosocial, and family functioning. Longitudinal studies and the use of advanced imaging techniques, to understand neurobiological correlates of functional reorganization, are essential to developing targeted intervention strategies to facilitate recovery.
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Affiliation(s)
- Mark T Mackay
- 1 Department of Neurology, Royal Children's Hospital, Parkville, Australia.,2 Murdoch Children's Research Institute, Parkville, Australia.,3 Department of Paediatrics, University of Melbourne, Parkville, Australia.,4 Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Maja Steinlin
- 5 Division of Paediatric Neurology, Development and Rehabilitation, University Children's Hospital, Bern, Switzerland.,6 Department of Paediatrics, University of Bern, Bern, Switzerland
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Bigi S, Dulcey A, Gralla J, Bernasconi C, Melliger A, Datta AN, Arnold M, Kaesmacher J, Fluss J, Hackenberg A, Maier O, Weber J, Poloni C, Fischer U, Steinlin M. Feasibility, safety, and outcome of recanalization treatment in childhood stroke. Ann Neurol 2018; 83:1125-1132. [DOI: 10.1002/ana.25242] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Sandra Bigi
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Andrea Dulcey
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Corrado Bernasconi
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Amber Melliger
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
| | - Alexandre N. Datta
- Department of Pediatric Neurology and Developmental MedicineUniversity of Basel Children's Hospital Basel
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Johannes Kaesmacher
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Joel Fluss
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital GenevaUniversity of Geneva Geneva
| | - Annette Hackenberg
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital ZurichUniversity of Zurich Zurich
| | - Oliver Maier
- Department of Pediatrics, Division of Child NeurologyChildren's Hospital St Gallen
| | - Johannes Weber
- Department of RadiologyCantonal Hospital St Gallen St Gallen
| | - Claudia Poloni
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital LausanneUniversity of LausanneLausanne Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital BernUniversity of Bern Bern
| | - Maja Steinlin
- Department of Pediatrics, Division of Child Neurology, University Children's Hospital BernUniversity of Bern Bern
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Kim ES, Mason EK, Koons A, Quinn SM, Williams RL. Successful Utilization of Mechanical Thrombectomy in a Presentation of Pediatric Acute Ischemic Stroke. Case Rep Pediatr 2018; 2018:5378247. [PMID: 29850345 DOI: 10.1155/2018/5378247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/07/2018] [Accepted: 03/26/2018] [Indexed: 11/17/2022] Open
Abstract
Guidelines regarding the management of acute ischemic stroke (AIS) in the pediatric population using mechanical recanalization procedures are lacking. We present a case of a 14-year-old male diagnosed in the Emergency Department with an acute onset stroke who underwent successful mechanical clot removal by interventional radiology.
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47
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Affiliation(s)
- Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Parkville, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Paul Monagle
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Haematology, Royal Children’s Hospital, Parkville, Australia
| | - Franz E. Babl
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Emergency Department, Royal Children’s Hospital Melbourne, Parkville, Australia
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