Incidence and Natural History of Pediatric Large Vessel Occlusion Stroke

Abstract

IMPORTANCEThe incidence and natural history of large vessel occlusion (LVO) stroke in children is largely unknown. These knowledge gaps limit the uptake of reperfusion therapies and reduce the efficiency of pediatric acute stroke pathways.OBJECTIVE To determine the incidence and natural history of pediatric LVO stroke. DESIGN, SETTING, AND PARTICIPANTSThis retrospective population-based cohort study was conducted between January 2010 and December 2019, with a mean (SD) follow-up of 37.0 (28.8) months. Admissions from all pediatric hospitals in the state of New South Wales, Australia, with a final diagnosis of arterial ischemic stroke (AIS) in patients 1 month to younger than 17 years were included. A total of 85 of 251 identified cases were excluded based on selection criteria. Data were analyzed from July 2020 to June 2021.EXPOSURES One-third of patients with LVO received mechanical thrombectomy with or without intravenous thrombolysis while the remainder were treated conservatively. MAIN OUTCOMES AND MEASURESThe primary outcome was the pediatric modified Rankin Scale (ped-mRS) score 3 months after stroke. Ordinal logistic regression was used to compare non-LVO, LVO without thrombectomy, and LVO with thrombectomy groups. RESULTSOf 161 included patients, 56 (34.8%) were female, and the mean (SD) age was 6.1 (5.4) years. A total of 166 AIS admissions were studied, and clinical follow-up was available for 164 of 166 admissions. LVO was present in 39 admissions (23.5%). The incidence of LVO stroke was 0.24 per 100 000 patients per year (95% CI, 0.13-0.35). Patients with LVO who did not receive thrombectomy (n = 26) had poor neurological outcomes, with 19 (73.1%) experiencing moderate to severe disability or death (ped-mRS score of 3 to 6) at 3 months (6 of 12 patients receiving thrombectomy [50.0%]; 25 of 38 patients with LVO [65.8%]). Patients with LVO without thrombectomy had significantly worse clinical outcomes than patients with non-LVO at 3 months (odds ratio, 3.64; 95% CI, 1.68-7.87; P = .001). Most patients with LVO presented within time windows suitable for thrombectomy (27 of 39 [69.2%] within 6 hours; 35 of 39 [89.7%] within 24 hours). CONCLUSIONS AND RELEVANCEIn this population-based cohort study, the natural history of pediatric patients with LVO stroke treated conservatively was poor, with most experiencing lifelong disability or death. Nearly 90% of pediatric patients with LVO presented within time windows suitable for thrombectomy.

Age-specific trends in intravenous thrombolysis and mechanical thrombectomy utilization in acute ischemic stroke in children under age 18

“…10 Increasing appreciation of the poor natural history of LVO strokes in children may also be contributing to increased uptake of MT despite lack of clinical trial evidence. 11 A recent study done using the National Inpatient Sample reported increased utilization of MT in children in the United States over the period 2010-2019. 12 We extend the results of this study by highlighting that the majority of this increased utilization is in older children.…”

Pediatric Stroke due to Thoracic Outlet Syndrome Treated with Thrombolysis and Thrombectomy: A Case Report

“…Given strong evidence that endovascular therapies such as thrombectomy significantly benefit select adults with large vessel occlusion [ 26 ], there is increasing interest in the use of these therapies for children with stroke. Although there are no randomized controlled data, mechanical thrombectomy may be safe in children [ 27 ], and guidelines suggest that thrombectomy may be appropriate in some children with large vessel occlusion who otherwise have a poor prognosis [ 28 , 29 ]. However, children with stroke are at higher risk of vasculopathies, which may not be appropriate for thrombectomy or increase the risks of thrombectomy [ 30 ].…”

Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke

“…More recently, a retrospective, population-based cohort study of childhood ischemic stroke in Australia demonstrated that children with large vessel occlusions who were treated with MT ( n = 13, with or without IV-tPA) had better functional outcomes compared with children with large vessel occlusions who were managed conservatively ( n = 26) [ 179 ]. The authors point out, importantly, that the absence of randomization or standardized MT selection criteria likely led to selection bias, and children who were treated with MT were older than those children managed conservatively, which may have driven, at least in part, the differences in outcomes.…”

“…An analysis from a US hospital showed that the major source of pediatric stroke diagnostic delays was late presentation to the emergency department, suggesting that future interventions aimed improving community recognition of stroke symptoms could help alleviate these delays [ 203 ]. Though ongoing improvements in time to pediatric stroke diagnosis are needed, a recent Australian study of pediatric large vessel occlusions showed that the majority presented early enough to be eligible for MT (69% presented within 6 hours of symptom onset and 90% within 24 hours) [ 179 ].…”