Malignant MCA territory infarction in the pediatric population: subgroup analysis of the Greater Cincinnati/Northern Kentucky Stroke Study

Abstract

Purpose Malignant middle cerebral artery (MCA) infarctions are thought to be rare in children. In a recent hospital-based study, only 1.3 % of pediatric ischemic strokes were malignant MCA infarctions. However, population-based rates have not been published. We performed subgroup analysis of a population-based study to determine the rate of malignant MCA infarctions in children. Methods In 2005 and 2010, all ischemic stroke-related emergency visits and hospital admissions among the 1.3 million residents of the five-county Greater Cincinnati/Northern Kentucky area were ascertained. Cases that occurred in patients 18 years and younger were reviewed in detail, and corresponding clinical and neuroimaging findings were recorded. Infarctions were considered malignant if they involved 50 % or more of the MCA territory and resulted in cerebral edema and mass effect. Results In 2005, eight pediatric ischemic strokes occurred in the study population, none of which were malignant infarctions. In 2010, there were also eight ischemic strokes. Of these, two malignant MCA infarctions were identified: (1) a 7-year-old boy who underwent hemicraniectomy and survived with moderate disability at 30 days and (2) a 17-year-old girl with significant prestroke disability who was not offered hemicraniectomy and died following withdrawal of care. Thus, among 16 children over 2 years, there were two malignant MCA infarctions (12.5 %, 95 % CI 0–29). Conclusions Malignant MCA infarctions in children may not be as rare as previously thought. Given the significant survival and functional outcome benefit conferred by hemicraniectomy in adults, future studies focusing on its potential role in pediatric patients are warranted.

Feasibility, safety, and outcome of recanalization treatment in childhood stroke

“…In our cohort, development of MMCAI occurred in 17 patients (ie, 17% of all MCA strokes) and was more frequent in patients receiving recanalization treatment than in the SC group. The frequency of MMCAI ranges between 1.3% and 18% in pediatric AIS patients and is associated with higher baseline pedNIHSS as shown in our cohort . Therefore, the higher frequency of MMCAI in the recanalization group is likely to be an epiphenomenon of more severe infarcts, rather than a complication attributable to the treatment modality itself.…”

“…The frequency of MMCAI ranges between 1.3% and 18% in pediatric AIS patients and is associated with higher baseline pedNIHSS as shown in our cohort. [27][28][29] Therefore, the higher frequency of MMCAI in the recanalization group is likely to be an epiphenomenon of more severe infarcts, rather than a complication attributable to the treatment modality itself.…”

Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

“…114,[411][412][413] Limited data suggest that hemicraniectomy may be most effective when performed early in the time course of the hemorrhage (24-48 hours), although there may be some utility in select cases at later times. 414,415 In a pediatric prospective cohort, 3 of 22 children with ICH had decompressive craniectomy; all were functionally independent. 397 When a child has a brain hemorrhage while receiving anticoagulation, anticoagulation is typically held or reversed.…”

Susceptibility-Weighted Imaging in Pediatric Arterial Ischemic Stroke: A Valuable Alternative for the Noninvasive Evaluation of Altered Cerebral Hemodynamics

“…Postischemic malignant edema is a life-threatening early complication of PAIS and is defined as a space-occupying AIS with severe brain swelling and mass effect, which may cause transtentorial herniation and brain death. 27,28 Impaired autoregulation in patients with stroke has been shown to lead to a rise in regional CBF followed by increased extravasation of fluid into the brain tissue and edema. 29 This process is enhanced by disruption of the blood-brain barrier.…”