Introduction/purpose Although pediatric stroke is far less common than adult acute ischemic stroke, the incidence is still as high as 13/100,000. In patients with moderate to severe strokes, based on a high pediatric NIH stroke scale greater than 17 or an acute basilar artery occlusion, the natural history of the disease is extremely poor despite increasingly earlier identification in the setting of more complex treatment for congenital heart disease. According to the most recent 2008 American Heart Association guidelines, treatment of pediatric stroke patients with TPA or thrombectomy should not be performed outside of a formalized research protocol. Despite the guidelines, there are numerous small series and case reports on intra-arterial therapy for acute ischemic stroke. In light of the recent randomized controlled adult mechanical thrombectomy trials in the setting of acute ischemic stroke, we sought to review all of the available literature on intra-arterial pediatric stroke intervention with a focus on modern mechanical devices.
Methods Retrospective meta-analysis for intra-arterial treatment of acute ischemic stroke in the pediatric population between 2008-present.
Results 18 case reports were included in the analysis between 2008 and 2014 with a total of 26 patients. The average age was 10.4 years (range 2–18) with 72.7% male. The most common site of vessel occlusion was the MCA, accounting for 12 cases. The basilar artery was occluded in 11 cases, ICA in 8 cases, and VA in 2 cases. The average time from symptom onset to intervention was 13.0 h (3–72+ hours). Stent retrievers (11 Solitaire, 2 Trevo, 1 Revive) were used in a majority of the included cases (53.8%) along with 8 cases using Merci devices (30.1%). Penumbra was used alone in 3 cases (11.5%), and was used in conjunction with other mechanical device (Merci, Solitaire, Trevo, Wingspan) in 26.9% of cases. Recanalization rates according to the TICI/TIMI scale showed 15 cases reported complete recanalization at 3 or 2b or 57%. There were relatively few complications, with 1 asymptomatic hemorrhage, 3 cases of small distal emboli, 1 case of cerebellar edema and hydrocephalus requiring craniectomy and ventricular drain, and a single case with a Merci device fracture. Based on the clinical description or provided mRS, the average modified Rankin scale was less than 1 (0.95) at longest available follow up period.
Conclusion Although mechanical thrombectomy for acute ischemic stroke in the pediatric population appears to have a low complication rate and a good clinical outcome, the sample size is too small to make any definitive conclusion.
The initial evidence suggests benefits (average most current mRS 0.95), however, this warrants further study in a randomized controlled trial or at minimum within a registry in the context of a formalized IRB.
Limitations Given the retrospective nature of this meta-analysis, the major limitations are sample size, which is inherent to the field of pediatric stroke, and reporting bias.
Disclosures S. Satti: 2; C; Stryker Neurovascular. T. Sivapatham: None. J. Chen: None.
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