Mechanical thrombectomy in childhood stroke is safe, effective

  • Sporns PB & al.
  • JAMA Neurol
  • 14/10/2019

  • Susan London
  • Clinical Essentials
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Takeaway

  • Endovascular recanalization is safe and effective when used in real-world practice to treat pediatric patients up to age 18 years experiencing acute stroke due to large-vessel occlusion.

Why this matters

  • Lack of high-level evidence supporting this treatment for children.
  • Difficulty of randomizing pediatric stroke patients.

Key results

  • Location of occlusion treated:
    • 86% anterior circulation.
    • 14% posterior circulation.
  • Overall, 22% of children received concomitant intravenous thrombolysis.
  • Neurologic outcomes:
    • Improvement in Pediatric National Institutes of Health Stroke Scale score from 14.0 (interquartile range [IQR], 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7.
    • Stable median modified Rankin scale score of 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months.
  • Complications:
    • 1% postinterventional bleeding.
    • 5% transient peri-interventional vasospasm.
  • Lower rate of symptomatic intracerebral hemorrhages in study pediatric cohort vs in HERMES meta-analysis of trials among adults (1.37% vs 2.79%).

Expert comment

  • In an editorial, Christine Fox, MD, MAS; Nomazulu Dlamini, MBBS, MSc, PhD, write, “Centers considering mechanical embolectomy in children should be prepared for this procedure by establishing local guidelines and multidisciplinary teams in consultation with pediatric neurologists with stroke expertise. Thrombectomy should ideally be performed by neurointerventional radiologists who have experience with both pediatric endovascular procedures and stroke embolectomy.”

Study design

  • Retrospective cohort study spanning 2000-2018 and 27 US, European stroke centers, among all 73 pediatric patients (
  • Main outcome: neurologic improvement (decrease in Pediatric National Institutes of Health Stroke Scale score).
  • Funding: None disclosed.

Limitations

  • Potential selection bias.
  • Heterogeneity of protocols, patients across centers.
  • Lack of control group.
  • Uncertain generalizability.