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Neuroimaging
Case Series
Neuroimaging selection for thrombectomy in pediatric stroke: a single-center experience
  1. Sarah Lee1,2,
  2. Jeremy J Heit3,
  3. Gregory W Albers1,
  4. Max Wintermark3,
  5. Bin Jiang3,
  6. Eric Bernier1,
  7. Nancy J Fischbein3,
  8. Michael Mlynash1,
  9. Michael P Marks3,
  10. Huy M Do3,4,
  11. Robert L Dodd3,4
  1. 1 Stanford Stroke Center, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
  2. 2 Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
  3. 3 Department of Radiology, Division of Neuroimaging & Neurointervention, Stanford University School of Medicine, Stanford, CA, USA
  4. 4 Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
  1. Correspondence to Dr. Sarah Lee; slee10{at}stanford.edu

Abstract

Background The extended time window for endovascular therapy in adult stroke represents an opportunity for stroke treatment in children for whom diagnosis may be delayed. However, selection criteria for pediatric thrombectomy has not been defined.

Methods We performed a retrospective cohort study of patients aged <18 years presenting within 24 hours of acute large vessel occlusion. Patient consent was waived by our institutional IRB. Patient data derived from our institutional stroke database was compared between patients with good and poor outcome using Fisher’s exact test, t-test, or Mann-Whitney U-test.

Results Twelve children were included: 8/12 (66.7%) were female, mean age 9.7±5.0 years, median National Institutes of Health Stroke Scale (NIHSS) 11.5 (IQR 10–14). Stroke etiology was cardioembolic in 75%, dissection in 16.7%, and cryptogenic in 8.3%. For 2/5 with perfusion imaging, Tmax >4 s appeared to better correlate with NIHSS. Nine patients (75%) were treated: seven underwent thrombectomy alone; one received IV alteplase and thrombectomy, and one received IV alteplase alone. Favorable outcome was achieved in 78% of treated patients versus 0% of untreated patients (P=0.018). All untreated patients had poor outcome, with death (n=2) or severe disability (n=1) at follow-up. Among treated patients, older children (12.8±2.9 vs 4.2±5.0 years, P=0.014) and children presenting as outpatient (100% vs 0%, P=0.028) appeared to have better outcomes.

Conclusions Perfusion imaging is feasible in pediatric stroke and may help identify salvageable tissue in extended time windows, though penumbral thresholds may differ from adult values. Further studies are needed to define criteria for thrombectomy in this unique population.

  • pediatrics
  • thrombectomy
  • embolic
  • MRI
  • Mr perfusion

https://doi.org/10.1136/neurintsurg-2019-014862

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    Footnotes

    • Contributors All listed authors have fulfilled the following criteria for authorship per ICMJE recommendations: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND Drafting the work or revising it critically for important intellectual content; AND Final approval of the version to be published; AND Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. SL conceived the study design, designed the data collection tool, consolidated and analyzed the data, and drafted and revised the paper. GWA conceived the study design, consolidated the data, and significantly revised the paper. MW, NJF, and BJ consolidated and analyzed the patient neuroimaging data and contributed to drafting and revising the paper. EB contributed to data collection tool design and consolidated the data. MM wrote the statistical analysis and cleaned and analyzed the data. JJH, MPM, HMD, and RLD conceived the study design, consolidated the data, enacted and analyzed the neurointerventional procedures and angiography imaging, and revised the paper.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests GWA: Ownership Interest; Significant; iSchemaView. Consultant/Advisory Board; Significant; iSchemaView, Medtronic.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Patient consent for publication Not required.