Successful Clinical Treatment of Child Stroke Using Mechanical Embolectomy

doi:10.1016/j.pediatrneurol.2013.06.008

Pediatric Neurology

Volume 49, Issue 5, November 2013, Pages 379-382

https://doi.org/10.1016/j.pediatrneurol.2013.06.008 Get rights and content

Abstract

Background

Stroke in childhood is less common than stroke in adults, but recent study estimate incidences up to 13/100,000. Mortality is decreasing but morbidity remains very high, with variable effects for two thirds of patients. Recent guidelines for optimal treatment in childhood stroke recommend advise against the use of thrombolysis, except for specific research protocols. There is no recommendation about intra-arterial thrombolysis or mechanical embolectomy. Various investigators have published cases of mechanical embolectomy in adult stroke, and a few cases of children are also reported.

PATIENT

We report a case of mechanical embolectomy 6 hours after a basilar artery occlusion in a healthy 7-year-old child. RESULT: He presented a successful medical outcome and had made a complete recovery.

Conclusion

This patient and the 10 published pediatric cases suggest mechanical embolectomy can be successfully used to treat basilar artery occlusion in children with coordination of neurology and interventional radiology services.

Introduction

In comparison with adults, stroke in childhood rarely occurs. But a recent study found an incidence estimate double that of prior US reports, a difference partially explained by the significant progress in noninvasive neuroimaging. Mortality in pediatric patients is decreasing but morbidity remains very high, with variable effects for two thirds of the patients. Neurological deficits shown by children alter their quality of life and development potential.¹ Because of the rarity of the disease, stroke in children is often not identified,² resulting in a considerable delay in treatment and subsequent poor outcomes. But rapid diagnosis determines therapeutic management and treatment options. Recent guidelines for optimal treatment in childhood stroke3, 4 recommend unfractionated heparin, low-molecular-weight heparin, or aspirin and advise against the use of thrombolysis (tissue plasminogen activator), except for specific research protocols. There is no recommendation about intra-arterial thrombolysis or mechanical embolectomy. Various investigators have published cases of mechanical embolectomy in adult stroke, and a few cases of children are also reported.5, 6, 7, 8, 9 We report here a successful medical outcome after a mechanical embolectomy in a 7-year-old child 6 hours after a basilar artery occlusion.

In the morning, a healthy 7-year-old boy suffered from a headache and transient visual disturbances for a few minutes to 1 hour, then returned to a normal state. At 4 pm, he was found on the ground, unconscious and unresponsive, with involuntary urination. No abnormal movements are noted but the child had been unattended for about 30 minutes. The boy gradually recovered consciousness.

The parents consult with a general practitioner, who notices that the child is sleepy and hypotonic and suffering from a right hemiparesis and ipsilateral facial paralysis. The score on the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) was estimated at 20⁸; as a result, the physician sent the boy with his parents to emergency services.

The resulting brain computed tomography found a dense basilar artery sign. Brain magnetic resonance imaging—including diffusion-weighted sequences and magnetic resonance angiography—was performed and revealed a hypointense intravascular basilar artery signal (Fig A), as found in brain computed tomography, corresponding to the thrombus in the artery: the entire upper half of the basilar artery was occluded (Fig E). There was also a hyperintense diffusion restriction associated with a coefficient of apparent left foot cerebral peduncle and the paramedian portion of the protuberance with fluid attenuated inversion recovery hyperintensity beginning in the same part of the brain. No hemorrhage was found.

As the patient's condition worsened, it was decided to transfer him to the neuroradiology center with the radiologist's agreement, after a pediatric neurologist had evaluated him. With the formal consent of his parents, the patient was placed under general anesthesia and underwent common femoral arterial puncture for vascular access. A diagnostic angiography confirmed basilar artery occlusion (Fig C). Based on the thrombus localization, mechanical thrombectomy was undertaken using the CAPTURE system catheter (Echelon 10 COVIDIEN) via a 4 Fr access and 4 Fr guiding catheter. No intravenous tissue plasminogen activator was administered before embolectomy. Basilar artery recanalization was seen in the follow-up angiography (Fig D).

Then patient was transferred to a pediatric intensive care unit and closely followed by a pediatric specialist and a pediatric stroke neurologist. Intravenous heparin was administered after the intervention and for the following 15 days; the patient was then given acetylsalicylic acid.

A total of 6 hours elapsed from the moment the boy was found unconscious to the arterial puncture.

Follow-up magnetic resonance angiogram 5 days after the stroke showed complete recanalization of the basilar artery and no hemorrhagica transformation (Fig F). A magnetic resonance imaging follow-up later found sequela of the pontine ischemia in the pontomedullary junction (Fig B). The patient's clinical outcome was excellent: the PedNIHSS score on admission was 20 and then 0 at discharge. The modified Rankin score at 30 days was 0.

An etiology was not found for this patient despite extensive cerebrovascular, cardiologic, and hematologic checks.

Section snippets

Discussion

Recommendations for child stroke management, from American Heart Association 2008, do not include the use of thrombectomy outside research protocols. Low-molecular-weight heparin, or unfractionated heparin, oral vitamin K antagonists such as warfarin, aspirin, and other antiplatelet agents are used for the secondary prevention of ischemic stroke. Thrombolytic therapy is not recommended and may only be considered in selected children with cerebral venous sinus thrombosis.⁴

Adult guidelines

Conclusion

Morbidity in child stroke is very high. Physicians should be trained to recognize signs and arrange a rapid transfer to a medical unit with a suitable medical platform.

As shown in some patients such as ours, mechanical endovascular treatment has a beneficial effect. It must be taken into account for the treatment options in childhood stroke, particularly in total basilar artery occlusion. However, this option requires coordination of neurology, intensive care, and interventional radiology

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Cited by (12)

Mechanical Thrombectomy in Pediatric Stroke: Report of Three New Cases
2020, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Up to 65% of pediatric stroke survivors sustain lasting neurologic deficits.4 Mortality from arterial stroke is lower in children than adults, and thus these children live with the burdens of cerebral injury.4-8 There is a need for more treatments to prevent morbidity and mortality after pediatric stroke.
Mechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children.
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.
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.
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.
Solitaire Stent Retriever Mechanical Thrombectomy in a 6-Month-Old Patient with Acute Occlusion of the Internal Carotid Artery Terminus: Case Report
2019, World Neurosurgery
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However, over the last decade a compilation of case reports has revealed that MT devices may be a safe option in children, particularly when the alternative of completed stroke has significant long-term consequences. A small but growing body of literature exists describing MT in the pediatric setting (Table 1).9-36 An analysis of 68 published cases of acute ischemic stroke in patients <18 years old found that MT significantly increased rates of recanalization and good outcome.8
Endovascular mechanical thrombectomy (MT) performed with stent retriever devices have proven efficacious in the treatment of adult patients with acute cerebral ischemia resulting from large-vessel occlusion. Recently, reports describing the use of MT in pediatric large-vessel occlusion have increased. However, these case reports are generally limited to older children and teenagers.
We report the use of a Solitaire (Medtronic, Minneapolis, Minnesota, USA) stent retriever for thrombectomy and revascularization of the right middle cerebral artery) in a 6-month-old patient.
To our knowledge, this is the youngest patient reported to be treated with MT using a stent retriever. This case adds to the growing literature that supports the use of MT as a stroke intervention in pediatric patients.
Thrombectomy for Acute Stroke in Childhood: A Case Report, Literature Review, and Recommendations
2017, Pediatric Neurology
The updated American Heart Association/American Stroke Association guidelines include recommendation for thrombectomy in certain adult stroke cases. The safety and efficacy of thrombectomy in children are unknown. An 8-year-old girl experienced acute stroke symptoms on two occasions while therapeutically anticoagulated on Novalung. Computed tomography scans showed proximal vessel thrombi, which were retrieved using a Trevo device without hemorrhagic complications. Postprocedural assessment found respective decreases in the National Institutes of Health Stroke Scale score from 10 to 4 and 12 to 7. The indications for treatment and early benefits observed in our case are consistent with other pediatric thrombectomy cases reported. However, publication bias and the heterogeneity of reported cases prevent drawing conclusions about the safety and efficacy of thrombectomy in children. Anticipating that updates to adult stroke guidelines would likely incite stroke providers to consider thrombectomy in children, our institution developed guidelines for thrombectomy before the index patient. Establishing institutional guidelines before considering thrombectomy in children may optimize patient safety.
Successful Manual Aspiration Thrombectomy in a Pediatric Patient
2016, Pediatric Neurology
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In contrast, mechanical thrombectomy may be effective in a more prolonged therapeutic window compared with tPA administration. Dubedout et al.20 and Sainz de la Maza et al.17 have demonstrated effectiveness of thrombectomy at six and eight hours from symptom onset, respectively. Moreover, Taneja et al.25 achieved complete recanalization and neurological improvement at 24 hours after symptom onset.
Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents.
We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours.
Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke.
Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy
2021, Stroke
Mechanical thrombectomy in pediatric stroke: Systematic review, individual patient data meta-analysis, and case series
2019, Journal of Neurosurgery: Pediatrics

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Clinical ObservationsSuccessful Clinical Treatment of Child Stroke Using Mechanical Embolectomy

Abstract

Background

PATIENT

Conclusion

Introduction

Section snippets

Discussion

Conclusion

Lancet Neurol

Chest

J Neurol Sci

Delay to diagnosis in acute pediatric arterial ischemic stroke

Stroke

Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young

Stroke

New mechanical recanalization devices - the future in pediatric stroke treatment?

J Invasive Cardiol

Mechanical embolectomy for treatment of large vessel acute ischemic stroke in children

J Neurointerventional Surg

Clinical Observations
Successful Clinical Treatment of Child Stroke Using Mechanical Embolectomy