Endovascular mechanical thrombectomy for acute stroke in young children

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.

Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature

“…There are several case reports and series of cases on mechanical thrombectomy in children, documenting the efficacy of this technique, as well as its safety, in a similar fashion as in adult patients. 4 , 8 , 10 , 13 , 16–21 Presently, several literature reviews and systematic reviews have already been published on thrombectomy in large vessel occlusion pediatric stroke. 2 , 8 , 9 , 11 , 12 , 22–25 Table 2 summarizes the largest recent series of cases in the literature.…”

“…Compatibility with devices used for adults seems to be an issue only until 5 years of age, from which point on intracranial vessels will have reached the adult proportions. 20 , 40 The use of smaller catheters/stent retrievers should be considered in smaller children. In the youngest patient in our series (2 year-old), a 3 mm stentriever was used, as well as a 3 F aspiration catheter.…”

A Stroke Alert Protocol Decreases the Time to Diagnosis of Brain Attack Symptoms in a Pediatric Emergency Department

“…9,11 With the advent of hyperacute therapies for the treatment of AIS and emerging evidence that these interventions may be safe and effective in children, it is imperative that children with AIS are identified in a timely fashion. [1][2][3][4][5][6] This requires enhanced community education and an organized system of evaluation and management once a patient presents for medical care. 20 We have shown that the establishment of a stroke alert system at a tertiary children's hospital, coupled with extensive internal educational efforts, significantly decreases the median time to diagnosis by neuroimaging of patients presenting to the ED with brain attack symptoms.…”

“…Increasingly, children with AIS are also being treated successfully with IV-tPA and mechanical thrombectomy. [1][2][3][4][5][6] The implementation of hyperacute therapies requires the timely identification of stroke, which has historically proved challenging in children; the median time from symptom onset to diagnosis of AIS in children is more than 20 hours. [7][8][9][10][11][12] A delay in diagnosis, coupled with the apparent safety and efficacy of IV-tPA in children, prompted 23 pediatric centers in North America to develop multidisciplinary stroke teams capable of emergent, around-the-clock response to patients with acute-onset focal neurologic deficits, 13,14 otherwise known as brain attack symptoms.…”

A Multidisciplinary Approach in the Management of a Paediatric Posterior Fossa Ischaemic Stroke: A Case Report

“…According to Felling et al, paediatric ischaemic stroke has an estimated adjusted incidence of 1.6 x 100,000 per year [1], which is lower than the incidence of stroke in adults, and the overall lifetime risk of acute ischaemic stroke is, on average, 18.3% in Western Europe [2]. In adults, posterior fossa strokes occur four times less frequently than anterior circulation strokes and are generally linked to atherosclerotic disease [3]. In children, posterior fossa strokes were linked (45%) to vertebral artery dissection (V2-V3 traits), mainly trauma-related dissection [4][5].…”