Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

Abstract

Importance: There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS).

Objectives: 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.

Design, setting, and participants: 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.

Exposure: IVT and/or EVT.

Main outcomes and measures: 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]).

Results: 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.

Conclusions and relevance: The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.

Figure 1.. Pediatric Acute Ischemic Stroke of Cardioembolic Origin Treated With Mechanical Thrombectomy

Acute ischemic stroke in a child aged 8 years with a clinical history of embolic heart disease presenting with sudden left hemiplegia and dysarthria. A-C: Baseline magnetic resonance imaging (MRI) performed 5 hours and 20 minutes after stroke onset. A, Axial maximum intensity projection reconstruction of time-of-flight angiography showing the occlusion of the proximal M1 segment of the right middle cerebral artery (MCA). B, Axial diffusion image showing hyperintensity limited to right caudate and lenticular nuclei, insula, and frontal cortex. C, Axial arterial-spin-labeling with cerebral blood flow cartography (ASL-CBF) showing markedly decreased perfusion throughout the right sylvian territory compared with the left side. D-E: Periprocedural digital subtraction angiography (DSA) images. D, Initial anteroposterior images after opacification of the right carotid territory confirming the occlusion (proximal M1 segment) of the right MCA. E, Final anteroposterior images after mechanical thrombectomy with stent retriever showing the patency without stenosis of the right MCA. F-H: Follow-up MRI performed 24 hours (D1) after the mechanical thrombectomy. F, Axial maximum intensity projection reconstruction of time-of-flight angiography showing restored patency of the right MCA territory. G, Axial diffusion image with no major extension of the ischemic core. H, Axial ASL-CBF cartography showing restored perfusion in the right MCA territory.

Figure 2.. Pediatric Acute Ischemic Stroke Caused by FCA Treated With Mechanical Thrombectomy

Acute ischemic stroke in a child aged 4 years with no medical history, presenting as a sudden left hemiplegia and facial palsy. A-C: Baseline magnetic resonance imaging (MRI) performed 2 hours and 50 minutes after stroke onset. A, Coronal maximum intensity projection reconstruction of time-of-flight angiography showing the occlusion of the distal M1 segment of the right middle cerebral artery (MCA). B, Axial diffusion image showing hyperintensity limited to right caudate. C, axial arterial spin labeling with cerebral blood flow (ASL-CBF) cartography showing markedly decreased perfusion throughout the right sylvian territory compared with the left side. D-E: Periprocedural digital subtraction angiography (DSA) images. D, Initial anteroposterior images after opacification of the right carotid territory confirming the occlusion (distal M1 segment) of the right MCA. E, Final anteroposterior images after mechanical thrombectomy with stent retriever showing restored patency of the right MCA; however, with significant residual stenosis. F-H: Follow-up MRI performed 24 hours (D1) after the mechanical thrombectomy. F, Axial MIP reconstruction of time-of-flight images showing the reclusion of the stenosed MCA. G, Axial diffusion image showing the extension of the ischemic core to the caudate nucleus and the posterior limb of the internal capsule; note the small focal ischemic spots in the superficial MCA territory. H, Axial ASL-CBF cartography showing the remaining decreased perfusion in the right MCA territory.