Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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 &lt; 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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 &lt; 5 years of age.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M<jats:sub>1</jats:sub>, 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.</jats:p></jats:sec>

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.…”

“…8 Recently, some reviews have gathered the published cases of endovascular treatment reported worldwide, and conclude that thrombectomy leads to high recanalization rates in children, similarly to adults, with excellent clinical outcome. 4 , 9 , 10 However, even in reviews, numbers of treated cases are still low, reporting as few as 29 cases in one review of the literature between 2008 and 2015, 9 38 cases in a national database study in the US, representing 1% of the total pediatric ischemic stroke cases, 2 and 44 cases in one review between 1990 and 2016. 11 Despite the published literature, prospective evidence is still lacking.…”

Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence

“… 35 , 36 Given the emerging literature data supporting the safety and efficacy of MT in childhood stroke treatment, but also the better functional outcomes of conservatively treated pediatric stroke in general compared with adult stroke, larger studies as well as international registries are needed to investigate the potential benefit in pediatric stroke from IVT. 37 Individualized patient management and close collaboration of Pediatricians with stroke specialists is necessary to take decisions regarding IVT administration, particularly for otherwise eligible for IVT pediatric patients, who present with significant neurological deficits within the 4.5 h time window. 38 With regard to the upper age limit of 80 years, the individual patient data meta-analysis of nine RCTs and a recent individual patient data meta-analysis combining both randomized and observational data have provided robust evidence that alteplase for AIS patients aged >80 years has a positive benefit–risk profile when administered according to the other regulatory criteria.…”

Childhood Arterial Ischaemic Stroke: Clinical Presentation, Risk Factors and Management

“…However, there has been an increasing number of published case reports and case-series describing thrombolysis and endovascular therapy as a feasible and promising treatment option even in very young children. [55][56][57][58][59] The recently published results of the Save ChildS Study, investigating feasibility, safety and outcome of endovascular recanalization of childhood AIS, are encouragingly positive. 60 In this retrospective, multicentrecohort study on 73 children treated in 27 international stroke centres, the safety profile of mechanical thrombectomy was comparable to those in randomized clinical trials for adults and outcome of most of the treated children was favourable.…”