Objective Case report of a pediatric acute ischemic stroke with left M1 middle cerebral artery occlusion with large penumbra who underwent mechanical thrombectomy with TICI 3 reperfusion.

Case An 11-year-old pediatric male patient with a history of congenital complete heart block presented to our hospital 30 minutes after the sudden onset of right sided weakness and aphasia. The patient was diagnosed with COVID-19 infection about 2 weeks before the stroke after presenting with upper respiratory tract infection symptoms, fatigue, cough, and muscle aches. On neurological examination, the patient was alert with expressive aphasia, left-sided partial gaze preference, right-sided upper motor neuron type facial weakness, right sided motor weakness in upper and lower extremity 2/5. The initial National Institute of Health Stroke Scale (NIHSS) score was 16. The computed tomography (CT) of the head revealed left middle cerebral artery (MCA) territory ischemia in the basal ganglia region (Alberta Stroke Program Early CT Score - 9) with no acute intracranial hemorrhage or mass effect. CT angiography demonstrated an occlusion of left M1 segment of the MCA. CT Perfusion imaging was suggestive of a large ischemic penumbra. Neuroendovascular service was consulted and candidacy for interventional treatment was confirmed.

Procedure The patient underwent endovascular thrombectomy under general anesthesia. The patient was placed on the angiographic table and the right femoral access was obtained using a micropuncture kit with a 19-gauge Seldinger needle. A short 6 French sheath (Terumo) was placed. The short sheath was exchanged for a 90 cm Neuronmax long sheath and advanced over a 5 French catheter (Penumbra Select) over a 0.035 inch GlidewireTM (Terumo) and placed at the cervical segment of the left internal carotid artery. The initial diagnostic angiogram revealed a complete occlusion of the left middle cerebral artery at the M1 segment. The guiding catheter was then advanced into the cervical segment of the left internal carotid artery, and a RED 72 aspiration catheter was advanced over a Velocity microcatheter to the proximal end of the thrombus. We successfully approximated the aspiration catheter to the proximal end of the thrombus and started the aspiration. Aspiration was continued for one minute before slowly withdrawing the catheter until free blood flow was achieved. Examination showed the removal of a large piece of thrombus, but control angiography after the first pass revealed that the left M1 MCA remained occluded. The same technique was repeated for a second pass using the RED 72 aspiration catheter, and the subsequent control left ICA angiography demonstrated TICI 3 reperfusion and patency of all branches of the left internal carotid artery. The patient was transferred to the pediatric ICU for post-thrombectomy care and stroke evaluation. Neurological examination post-thrombectomy revealed significant improvement with an NIHSS score of 2 on day 1 after the procedure. The patient was started on aspirin 81 mg for secondary stroke prophylaxis.

Conclusions This is a first known report of a successful mechanical thrombectomy in a pediatric patient due to a large vessel occlusion related to congenital complete heart block and recent COVID-19 infection.

Disclosures J. Ansari: None. D. Mata Canadas: None. M. Ayub: None. J. Caskey: None. P. Simoncini: None. R. Riel-Romero: None. P. Sharma: None. D. Jordan: None. H. Cuellar: None.