Pediatric Acute Ischemic Stroke Research Articles

Mechanical Thrombectomy for Pediatric Stroke: Focal Cerebral Arteriopathy Versus Cardioembolic Etiologies-Pooled Analysis of the Save ChildS and KidClot Cohort.

The study aimed to compare outcomes of mechanical thrombectomy (MT) in pediatric patients with acute ischemic stroke (AIS) caused by focal cerebral arteriopathy (FCA) versus cardioembolism (CE). Data from the Save ChildS and KidClot cohorts were merged. Children with AIS because of FCA or CE that underwent MT were included. The study used the Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation (CASCADE) for stroke cause assessment. Descriptive statistics and multivariable regression models were used to analyze final modified thrombolysis in cerebral infarction (mTICI) scores, periprocedural complications, and functional outcomes assessed by the modified Rankin scale (mRS) at 6 to 12 months. The analysis included 60 children with 14 FCA and 46 CE cases. CE etiology was associated with better revascularization (good to excellent thrombolysis in cerebral infarction scores) and shift toward better outcomes (common adjusted odds ratio of mRs for CE vs FCA: 0.27, 95% CI: [0.06-0.97], p = 0.039), with no difference in favorable outcome rates. FCA was associated with significantly lower rates of excellent revascularization (21% vs 65%, p < 0.001). No difference in complications' rates was observed between the groups (7.2% in FCA vs 5.5%, p = 0.69). We found that pediatric AIS because of CE etiology has more favorable procedural outcomes compared to FCA following MT. This translated to mixed functional outcomes that may be more favorable in the CE group. These findings highlight the need for further research to refine treatment protocols for pediatric stroke, particularly in understanding and managing FCA in children. ANN NEUROL 2024.

First Reported Case of Tenecteplase for Pediatric Acute Ischemic Stroke (P7-5.021)

First Reported Case of Tenecteplase for Pediatric Acute Ischemic Stroke (P7-5.021)

A Review of an Interfacility Transport Program Pediatric Stroke Clinical Practice Guideline.

Pediatric acute ischemic stroke is a rare diagnosis that requires timely recognition and definitive management to prevent morbidity and mortality. Children often present to primary care offices, urgent care clinics, and adult emergency departments for evaluation of symptoms that may be signs and symptoms of stroke. Currently, there are no published prehospital or transport protocols specific to pediatric acute ischemic stroke. The Children's Mercy Hospital Critical Care Transport Team (CMCCT) created a pediatric-specific clinical practice guideline (CPG) for suspected acute ischemic stroke. This retrospective, descriptive study reports pediatric patients aged younger than 18 years who met criteria for the pediatric stroke CPG and required interfacility transport by CMCCT over a 4- year period. Large vessel occlusion (LVO) scores used in adults were calculated retrospectively. Seventeen patients met inclusion criteria. Four (24%) of 17 had radiographic evidence of acute thrombus, 3 of whom received alteplase and/or endovascular clot retrieval. Median age of confirmed stroke was 83 months (interquartile range, 65-148) compared with 177 months for nonstroke (interquartile range, 169-191), P = 0.126. The most common presenting symptom was hemiplegia in the confirmed stroke group. The confirmed stroke group scored significantly lower on the Glasgow Coma Scale (median of 8 vs 15, P = 0.014), significantly higher on the Los Angeles Motor Scale LVO score (median 4 vs 0, P = 0.021), and significantly higher on the Rapid Arterial Occlusion Evaluation LVO (median 4 vs 0, P = 0.036). To our knowledge, the CMCCT CPG is the first pediatric transport protocol aimed at recognition and management of pediatric stroke described in the literature. Retrospective calculation of LVO scores show that they may be helpful in application to pediatric patients.

Endovascular treatment of acute ischemic stroke in childhood: A comprehensive literature review based on the experience of a single center

Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood.The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS.The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children.The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points.The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise.Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.

A pediatric case series of acute ischemic stroke with concurrent influenza

PurposeTo highlight a case series of three pediatric patients who presented with acute ischemic stroke (AIS) in the setting of influenza illness. MethodsRetrospective chart review was performed. ResultsThree patients of ages 23 months (patient 1), 2 years (patient 2), and 4 years (patient 3) presented with acute hemiparesis or focal status epilepticus. Two patients had trisomy 21 and trivial cardiac septal defects, and one was previously healthy. All patients tested positive for influenza within a week of symptoms. Neuroimaging showed AIS involving right deep grey matter and bilateral posterior cortex in patient 1, left parietal lobe in patient 2, and right parietotemporal and deep grey matter in patient 3. Vascular abnormalities were found and included moyamoya syndrome in two patients and focal arteriopathy in one patient. For secondary stroke prevention, patients 2 and 3 were started on clopidogrel initially and later transitioned to aspirin after the resolution of the acute influenza infection. Patient 1 was started on aspirin at diagnosis since he was not acutely ill. ConclusionsThis case series highlights three pediatric patients with AIS with underlying arteriopathy in the setting of influenza infection. Pediatric AIS is a separate entity from adult stroke. There is limited understanding of its underlying pathophysiology. The most common risk factors described in literature for pediatric AIS are arteriopathy and cardiac disorders. Minor infection may be a significant risk factor in a child that is predisposed to vascular insult. There is some evidence in literature to suggest that vaccination against such illnesses may be protective for AIS.

Incidence, Characteristics, and Outcomes of Stroke in Pediatric Patients with Celiac Disease.

(1) Background: Celiac disease (CD) can cause long-term inflammation and endothelial dysfunction and has been cited as a risk factor for acute ischemic stroke (AIS) in pediatric patients. However, the rate and outcomes of AIS in pediatric patients with CD has not been explored in a large population. Our objective is to explore the rate, severity, and outcomes of CD amongst pediatric AIS patients on a nationwide level. (2) Methods: The National Inpatient Sample (NIS) database was queried from 2016 to 2020 for pediatric patients with a principal diagnosis of AIS. Patients with a concurrent diagnosis of CD (AIS-CD) were compared to those without (AIS). Baseline demographics and comorbidities, clinical variables of severity, hospital complications, and the rates of tissue plasminogen activator (tPA) and mechanical thrombectomy were compared between the two groups. The main outcomes studied were mortality, discharge disposition, length of stay (LOS), and total hospital charges. (3) Results: Of 12,755 pediatric patients with a principal diagnosis of AIS, 75 (0.6%) had concurrent CD. There were no differences in the severity, discharge disposition, or mortality between the AIS-CD and AIS patients. Patients with AIS-CD were more likely to receive tPA at an outside hospital within 24 h of admission (p < 0.01) and more likely to undergo mechanical thrombectomy (p < 0.01) compared to the AIS patients. (4) Conclusions: CD patients made up only 0.6% of all pediatric AIS patients. No differences in the severity, mortality, or discharge disposition suggests a minimal to absent role of CD in the etiology of stroke. The CD-AIS patients were more likely to receive a tPA or undergo a mechanical thrombectomy; studies are needed to confirm the safety and efficacy of these interventions in pediatric patients.

The Spectrum of Pediatric Infection-Associated Intracranial Arteriopathies and Acute Ischemic Stroke at 2 Eastern Indian Tertiary Care Centres.

Major and minor pediatric infections may cause intracranial arteriopathies, the long-term outcome of which we investigated and identified the factors influencing the progression/resolution of arteriopathies. We collected the clinical and radiological data of children aged 1 month-15 years who had ischemic stroke with definite arteriopathy following a recent febrile infection. Repeated neuroimaging was done over the next year to ascertain recurrent strokes and the progression and resolution of arteriopathies. The anterior circulation was more frequently affected (83.33%), predominantly involving the middle cerebral artery (41.67%), resolving in 20.84% of cases and progressing in 33.33% of cases. Lesions were commonly unilateral (54.17%) and stenotic (75%), resulting predominantly in cortical infarcts (45.83%), with hemiparesis being the most common neurodeficiency. Apart from tubercular meningitis patients, others had a good functional outcome. Lower age, minor infections, and unilateral arteriopathies had a significantly higher chance of resolution. Postviral arteriopathies had a significantly lower chance of progression compared with those following bacterial infections. Progressive and bilateral arteriopathies were significantly associated with worse outcomes and recurrent strokes.

Acute Ischemic Stroke Large Vessel Occlusion treated with Mechanical Thrombectomy in the Pediatric Populatio (P8-5.015)

<h3>Objective:</h3> We sought to assess the safety and efficacy of mechanical thrombectomy performed in children at our institution for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). <h3>Background:</h3> AIS due to large vessel occlusion (LVO) is relatively rare in the pediatric population, and evidence supporting thrombectomy in children is limited. The use of thrombectomy in the pediatric population is extrapolated from data in the adult stroke literature. <h3>Design/Methods:</h3> We performed a retrospective chart review of pediatric patients (age &lt; 18 years) with AIS due to LVO who underwent thrombectomy at our comprehensive academic stroke center from January 2019 to June 2022. <h3>Results:</h3> We identified 4 cases of pediatric AIS with LVO treated with thrombectomy. The mean age was 12 years old (range, 9–17), 3 were males. The mean National Institutes of Health Stroke Scale was 16 (range, 10 to 28). One patient received partial thrombolysis (aborted with 20% of dose received). Prior to thrombectomy, 1 patient had CT brain perfusion which showed MCA mismatch favorable for thrombectomy, whereas the remaining 3 patients had MRI brain showing acute infarct in the territory of LVO. LVO sites included M1 occlusion (2), carotid T occlusion (1), and M2 occlusion (1). All 4 patients had successful revascularization including 3 patients with thrombolysis in cerebral infarction (TICI) 3 and 1 patient with TICI 2b. There were no symptomatic hemorrhages. The mean time from last known normal to groin puncture was 5.7 hours (range, 2.9 to 9.2). The clinical outcomes included 2 patients with modified rankin scores (mRS) 1 and 2 patients with mRS 3. <h3>Conclusions:</h3> In our case series of pediatric AIS cases with LVO, thrombectomy was feasible and associated with successful revascularization. There were no safety concerns. The majority of cases were diagnosed by MRI brain, highlighting the difficulty in diagnosis of LVO in the pediatric population. <b>Disclosure:</b> Mrs. Glenn has nothing to disclose. Dr. Lee has nothing to disclose. Shahid Nimjee has nothing to disclose. The institution of Dr. Lo has received research support from NIH. Dr. Lo has received publishing royalties from a publication relating to health care. Mrs. Forrest has nothing to disclose. Randheer Yadav has stock in Quest Recovery Center LLC. Patrick Youssef has nothing to disclose.

Abstract Number ‐ 2: Intravenous Thrombolysis for Pediatric Ischemic Stroke: Twenty Years of Population‐Level Data in the United States

Introduction Although intravenous thrombolysis (IVT) represents standard‐of‐care treatment for acute ischemic stroke (AIS) in eligible adult patients, definitive evidence‐based guidelines and randomized clinical trial data evaluating its safety and efficacy in the pediatric population remain absent from the literature. We aim to evaluate the utilization and outcomes of IVT for the treatment of pediatric AIS using a large national registry. Methods Weighted hospitalizations for pediatric (&lt;18 years of age) AIS patients were identified in the National Inpatient Sample during the period of 2001 to 2019. Complex samples statistical methods were performed to assess unadjusted and adjusted outcomes in patients treated with IVT or other medical management. Results Among 13,901 pediatric AIS patients, 270 (1.9%) were treated with IVT monotherapy (median age 12.8 years). IVT‐treated patients developed any intracranial hemorrhage (ICH) at a rate of 5.6% (n = 15), and 71.9% (n = 194) experienced favorable functional outcomes at discharge (to home or to acute rehabilitation). Following propensity‐score adjustment for age, acute stroke severity, infarct location, and etiological/comorbid conditions, IVT was not associated with an increased risk of any ICH [5.6% vs. 5.4%, p = 0.931; adjusted odds ratio (aOR) 1.01, 95% confidence interval (CI) 0.48, 2.14, p = 0.971], nor with favorable functional outcome (71.9% vs. 74.5%, p = 0.489; aOR 0.88, 95% CI 0.60, 1.29, p = 0.511) in comparison with other medical therapy. Conclusions Twenty years of population‐level data in the United States demonstrate that pediatric AIS patients treated with IVT experienced high rates of favorable outcomes without an increased risk of hemorrhagic transformation.

Clinical analysis of 4 acute ischemic stroke children treated with endovascular thrombectomy

Objective: To assess the feasibility of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) in children. Methods: Clinical data and follow-up information of 4 AIS children who received EVT in the Department of Intervention & Hemangioma at the Children's Hospital of the Capital Institute of Pediatrics from December 2020 to June 2021 were collected retrospectively. The vascular recanalization after EVT was assessed by the modified thrombolysis in cerebral infarction (mTICI) score. Efficacy outcomes were assessed with initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and the modified Rankin scale (mRS) score at 3 and 6 months after treatment. Safety assessments included perioperative complications and intracranial hemorrhage post-treatment. Results: A total of 5 EVT treatment were performed on 4 children with AIS, of whom 3 were male. The age of onset was 4.6, 13.8, 7.8, 8.0, 8.9 years, respectively. The time from symptom onset to initiation of EVT was 19.0, 25.0, 22.0, 4.0, 16.5 hours, respectively and all patients achieved successful recanalization of the vessel after EVT (mTICI≥2b). The PedNIHSS score was 39, 14, 25, 39, 24 before treatment and decreased to 8, 1, 12, 39, 5 at discharge. All the procedures were performed with no perioperative complications. Only 1 patient with congenital heart disease had a recurrent AIS with malignant brain oedema and brain hernia. Although the occluded vessels were successfully recanalized,the symptoms were not improved and this patient died after treatment abandonment. The other 3 patients achieved good recovery at 6 months postoperatively. The mRS score of 3 patients was 3, 1, 2 at 3 months after EVT and decreased to 2, 1, 1 at 6 months. Conclusion: EVT treatment may be feasible and safe for pediatric AIS due to large vessel occlusion even when the treatment was initiated 6 hours post stroke, but children with heart disease may have a dismal prognosis.

Evaluation of risk factors, functionalities, and quality of life in patients with pediatric acute arterial ischemic stroke.

This study aimed to evaluate the etiology and prognosis of patients followed up for pediatric acute arterial ischemic stroke. The clinical characteristics and etiology of patients aged 1 month-18 years who had acute arterial ischemic stroke between January 2010 and December 2020 were retrospectively evaluated. At last follow-up, the patients` functionality (Barthel Index, Functional Independence Measure), quality of life (SF-36 questionnaire), and motor outcomes (Gross Motor Function Classification System) were recorded prospectively/crosssectionally. Forty children (25 boys) with a median current age of 112.5 months (range: 3.6-294) were included in the study. The most frequent etiology was prothrombotic disorders, and the most important factor associated with long-term mortality was valvular heart disease. Of the 27 (67.5%) surviving patients, 29.6% had positive motor outcomes and 29.6% were independent according to the Barthel Index. In terms of quality of life, SF-36 scores were highest in the pain scale and lowest in emotional role difficulty. Determining the etiology and evaluating prognosis are important to plan effective treatment and rehabilitation for pediatric acute arterial ischemic stroke.

Age-specific trends in intravenous thrombolysis and mechanical thrombectomy utilization in acute ischemic stroke in children under age 18.

To evaluate current trends in the utilization of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) in various age groups of children in the United States. We conducted a serial cross-sectional study using primary AIS admissions in children ⩽ 17 years (weighted n = 2807) contained in the 2009-2019 KIDS Inpatient Database. Age-specific utilization frequency of IV-tPA and MT were calculated. Multivariable-adjusted models were used to evaluate demographic predictors of treatment. From 2009 to 2019, there were 2807 AIS admissions in children in the KID of which 55.9% were in boys and 29.9% were 15-17 years old.128 (4.6%) received IV-tPA. IV-tPA utilization differed by age (5-9 years: 3.1%, 15-17 years 8.1% p value < 0.001). Overall MT usage was 2.3% and this also varied by age (1-4 years: 0.9% and 15-17years 4.0%, p value = 0.006). IV-tPA utilization almost tripled across the study period (2.5% 2009 to 6.5% in 2019, p value = 0.001) while MT use more than doubled over time (1.2% in 2009 and 3.0% in 2019, p value = 0.048). Increased IV-tPA utilization was seen primarily in children 10-14 years (0.8% in 2009 to 7.2% 2019, p value = 0.005) and 15-17 years (5.4% in 2009 to 10.4% in 2019, p value = 0.045). Utilization in younger age groups remained unchanged over time. MT usage was very variable across various age groups over time. IV-tPA and MT utilization increased over time in nonchildren's hospitals (both p values < 0.05) but usage in designated children's hospitals did not change significantly over time. In multivariable models, there was no significant difference in odds of IV-tPA and MT use by sex, race or insurance status. IV-tPA and MT utilization in pediatric AIS increased in the United States over the past decade mainly in older children 10-17 years. Utilization increased mainly in patients hospitalized in nonchildren's hospitals. Usage in children's hospitals did not change significantly over time.

317 Implementation of a Stroke Response Team at a Pediatric Emergency Department

Acute ischemic stroke (AIS) is an important cause of morbidity and mortality in children. Timely usage of hyperacute therapies, such as intravenous tissue plasminogen activator (IV-tPA) and mechanical thrombectomy, appear to be safe and effective in children. Despite this, early recognition and diagnosis of pediatric AIS within the therapeutic window for hyperacute therapies remains a challenge. Our objective is to improve timely diagnosis of AIS at our pediatric tertiary hospital emergency department (ED) through the implementation of an interdisciplinary stroke alert team and improved coordination of care.

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS). To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS. The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment between January 1, 2015, and May 31, 2018. Data analysis was performed from January 1, 2015, to May 31, 2019. IVT and/or EVT. Primary outcome was day 90 favorable outcome (modified Rankin Scale [mRs] 0-2, with 0 indicating no symptoms and 6 indicating death). Secondary end points included 1-year favorable outcome (mRs, 0-2), mortality, and symptomatic intracerebral hemorrhage. Other measures included the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), with pedNIHSS 0 indicating no symptoms, 1 to 4 corresponding to a minor stroke, 5 to 15 corresponding to a mild stroke, greater than 15 to 20: severe stroke, and the adult Alberta Stroke Program Early CT Score (ASPECTS), which provides segmental assessment of the vascular territory, with 1 point deducted from the initial score of 10 for every region involved (from 10 [no lesion] to 0 [maximum lesions]). Overall, 68 children were included in 30 centers (IVT [n = 44]; EVT [n = 40]; 44 boys [64.7%]; median [IQR] age, 11 [4-16] years; anterior circulation involvement, 57 [83.8%]). Median (IQR) pedNIHSS score at admission was 13 (7-19), higher in the EVT group at 16 (IQR, 10-20) vs 9 (6-17) in the IVT only group (P < .01). Median time from stroke onset to imaging was higher in the EVT group at 3 hours and 7 minutes (IQR, 2 hours and 3 minutes to 6 hours and 24 minutes) vs 2 hours and 39 minutes (IQR, 1 hour and 51 minutes to 4 hours and 13 minutes) (P = .04). Median admission ASPECTS score was 8 (IQR, 6-9). The main stroke etiologies were cardioembolic (21 [30.9%]) and focal cerebral arteriopathy (17 [25.0%]). Median (IQR) time from stroke onset to IVT was 3 hours and 30 minutes (IQR, 2 hours and 33 minutes to 4 hours and 28 minutes). In the EVT group, the rate of postprocedure successful reperfusion (≥modified Treatment in Cerebral Infarction 2b) was 80.0% (32 of 40). Persistent proximal arterial stenosis was more frequent in focal cerebral arteriopathy (P < .01). Death occurred in 3 patients (4.4%). Median pedNIHSS reduction at 24 hours was 4 (IQR, 0-9) points. Intracerebral hemorrhage occurred in 4 patients and symptomatic intracerebral hemorrhage occurred in 1 patient, all in the EVT group. The median mRS was 2 (IQR, 0-3) at day 90 and 1 (IQR, 0-2) at 1 year, which was not significantly different between EVT and IVT only groups, although different in initial severity. The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.

Extended time window mechanical thrombectomy for pediatric acute ischemic stroke.

Endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) remains an off-label procedure seldom utilized in the pediatric population; this holds especially true for patients presenting outside the standard 6-hour time window. In this review we describe the published literature regarding usage of the extended time window EVT in pediatric stroke. We searched PubMed for all pediatric AIS cases and case series that included patients treated with extended time window EVT. We found data from 38 cases found in 27 publications (15 case reports and 12 case series). The median age was 10 years; 60.5% males. The median NIHSS before EVT was 13 with a median time-to-treatment of 11 hours. The posterior circulation was involved in 50.0%. Stent retrievers were used in 68.5%, and aspiration in 13.2%. Angiographic outcome TICI ≥2B was achieved in 84.2%, whereas TICI˂2B was reported in 10.6%. A favorable clinical outcome (NIHSS score ≤4, modified Rankin score ≤1, or Pediatric Stroke Outcome measure score ≤1) occurred in 84.2%. Eight cases that did not report the clinical outcome employing a standardized scale described mild to absent neurological residual deficits. This study found data that supports that extended window EVT produces high recanalization rates and good clinical outcomes in pediatric patients with AIS. Nevertheless, the source materials are indirect and contain substantial inconsistencies with an increased risk of bias that amount to low evidence strength.

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke

Evidence regarding the utilization and outcomes of endovascular thrombectomy (EVT) for pediatric ischemic stroke is limited, and justification for its use is largely based on extrapolation from clinical benefits observed in adults. Weighted discharge data from the National Inpatient Sample were queried to identify pediatric patients with ischemic stroke (<18 years old) during the period of 2010 to 2019. Complex samples statistical methods were used to characterize the profiles and clinical outcomes of EVT-treated patients. Propensity adjustment was performed to address confounding by indication for EVT based on disparities in baseline characteristics between EVT-treated patients and those medically managed. Among 7365 pediatric patients with ischemic stroke identified, 190 (2.6%) were treated with EVT. Utilization significantly increased in the post-EVT clinical trial era (2016-2019; 1.7% versus 4.0%; P<0.001), while the use of decompressive hemicraniectomy decreased (2.8% versus 0.7%; P<0.001). On unadjusted analysis, 105 (55.3%) EVT-treated patients achieved favorable functional outcomes at discharge (home or to acute rehabilitation), while no periprocedural iatrogenic complications or instances of contrast-induced kidney injury were reported. Following propensity adjustment, EVT-treated patients demonstrated higher absolute but nonsignificant rates of favorable functional outcomes in comparison with medically managed patients (55.3% versus 52.8%; P=0.830; adjusted hazard ratio, 1.01 [95% CI, 0.51-2.03]; P=0.972 for unfavorable outcome). Among patients with baseline National Institutes of Health Stroke Scale score >11 (75th percentile of scores in cohort), EVT-treated patients trended toward higher rates of favorable functional outcomes compared with those treated medically only (71.4% versus 55.6%; P=0.146). In a subcohort assessment of EVT-treated patients, those administered preceding thrombolytic therapy (n=79, 41.6%) trended toward higher rates of favorable functional outcomes (63.3% versus 49.5%; P=0.060). This cross-sectional evaluation of the clinical course and short-term outcomes of pediatric patients with ischemic stroke treated with EVT demonstrates that EVT is likely a safe modality which confers high rates of favorable functional outcomes.

Recanalization treatment for pediatric acute ischemic stroke: a nationwide french registry

There's to date no solid evidence that revascularization strategies improve functional outcome in children. In this study of consecutive children with AIS stroke patients treated with intravenous thrombolysis (IVT) and, or endovascular treatment (EVT) we aimed to provide up to date estimates of revascularization strategies’ safety and efficacy profiles in the pediatric population. The French KIDCLOT multicentric nationwide retrospective study (NCT03887143) collected data of consecutive children aged >28 days and <18 years old with acute ischemic stroke who had a recanalization treatment between January 1rst 2015 and May 31rst 2018. Overall, 68children from 30 participating centers were analyzed including 24 girls (35.3%), with a mean age at stroke onset of 10.1 ± 5.7 years old. IVT was administered in 44 patients (64.7%) and EVT was performed in 40 children (58.8%). Mean pedNIHSS at admission was 13.1 ± 6.1 overall and was higher in patients treated with MT (15.6 ± 6.2 vs 10.6 ± 6, p<0.01). Mean time from stroke onset to imaging was higher in patients treated with MT (286.5 ± 244.2 vs 189 ± 97.6, p=0.03). AIS was due to an anterior circulation occlusion in 57 children (83.8%). Median [IQR] admission ASPECTS score was 8 [7–9] and did not differ significantly between patients treated with or without MT. Main stroke etiologies were cardio-embolic (30.9%), focal cerebral arteriopathy (FCA, 25%). Mean time from onset to IVT was 201.7 ± 73 overall and was higher in patients treated with MT (231,8±52,6 vs 174,6±76,2 p=0,02). In MT patients, the rate of successful reperfusion (≥mTICI 2b) was 80% (32/40). Persistent proximal arterial stenosis on final DSA images was significantly more frequent in FCA cases (p<0,01). Death was observed in 3 patients (4.4%), all within the first week. Mean pedNIHSS improvement at 24 hours was 4.2 ± 6.9 overall, slightly but not significantly better in the MT group (5.1 ± 7 vs 3.4 ± 6.9 p=0.34). In the MT group, one patient suffered of intracranial arterial perforation, and one other of embol in a new territory. ICH and SICH were observed in four and one patients respectively, all in the MT group. The median mRS score at 3 months was 2 (IQR, 0-3) and further improved to 1 (IQR, 0-2) after 12 months, not different between MT and no-MT group. This study provides encouraging safety data in a population of AIS children treated with either IVT, EVT or both. One-year neurological outcome was good in three quarter of the study sample. EVT is feasible with rates of successful revascularization and procedural duration of similar magnitude to those found in adult populations (references 1 to 5)

Primary mechanical thrombectomy for anterior circulation stroke in children: Report of two cases and literature review.

Introduction and importancePediatric acute ischemic stroke is a rare but devastating condition with substantial rates of morbidity and mortality. Endovascular treatment is standard acute revascularization therapy for stroke in adults, but it is not well-studied in pediatrics. We report the successful treatment of two pediatric cases of anterior circulation stroke with primary mechanical thrombectomy.Case presentationTwo Asian children, aged 13 and 8 years, presented to Dr. Soetomo General Academic Hospital in September 2020 and April 2021, respectively, with hemiplegia and significant Pediatric National Institutes of Health Stroke Scale (Ped NIHSS) scores. Head CT scans demonstrated hyperdense middle cerebral artery signs, suggesting large-vessel occlusion stroke. Both patients underwent emergent thrombectomy within 5 and 10 h after initial onset, and successful recanalization was achieved within an hour. Both demonstrated good neurological recovery and there was no recurrent stroke during follow-up.Clinical discussionThrombectomy has appeal for childhood acute ischemic stroke (AIS) due to a longer post-stroke time window for intervention. As the short-term outcome, a significantly reduced Ped NIHSS score is achieved. Long-term outcomes are measured by modified Rankin Scale (mRS) scores. A literature review from 2016 to 2021 yielded 21 pediatric case reports of primary mechanical thrombectomy for anterior circulation stroke (including the present cases). We compare our cases with the published literature to discuss the short-term and long-term outcomes.ConclusionMechanical thrombectomy holds promise as a treatment modality in pediatric AIS. These case reports described successful primary mechanical thrombectomy for AIS treatment in children.

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke: A Multi-Institutional Experience of Technical and Clinical Outcomes

Ravindra, Vijay M MD, MSPH; Alexander, Matthew MD; Taussky, Philipp MD; Bollo, Robert J MD; Hassan, Ameer E DO; Scoville, Jonathan P MD; Griauzde, Julius MD; Awad, Al-Wala MD; Jumaa, Mouhammad MD; Zaidi, Syed MD; Lee, Jonathan J MD; Hafeez, Muhammad Ubaid MD; Nascimento, Fábio A MD; LoPresti, Melissa A MD, MPH; Couldwell, William T MD, PhD; Hetts, Steven W MD; Lam, Sandi K MD; Kan, Peter MD; Grandhi, Ramesh MD

Reperfusion treatment in pediatric acute ischemic stroke: A single-centre experience

Reperfusion therapy