Non-routine thrombectomy in pediatric arterial ischemic stroke

Abstract

Purpose: Unlike in adults, the indications and techniques for mechanical thrombectomy for arterial ischemic stroke (AIS) in children are not clearly established. The medical and interventional management of children with acute large vessel occlusion may entail the modification of the standardized management of this condition in adults. We present six cases of children who underwent non-routine thrombectomy for AIS.

Methods: We retrospectively reviewed the records of children diagnosed with AIS between 2015 and 2023 and evaluated patient characteristics, procedural technical data, and final clinical outcomes. Procedures deviating from the current definition and indications for AIS treatment in adults as well as previously reported pediatric thrombectomy cases were defined as non-routine thrombectomy.

Results: Seven non-routine thrombectomy procedures in six children were included in the study. The National Institutes of Health Stroke Scale scores on admission ranged from 4 to 35; no procedure-related mortality or major neurologic morbidity occurred. One child died of causes related to the initial severe heart failure and stroke; otherwise, all the children had a modified Rankin scale score of 0 to 1 at follow-up. Unique clinical and procedural features in our case series included presentation with acute stent occlusion (two children), bilateral simultaneous internal carotid artery occlusions associated with a unilateral tandem middle cerebral artery (MCA) occlusion (one child), MCA occlusion caused by thromboembolism of the atrial myxoma (one child), and very distal (one child) or delayed thrombectomy (two children).

Conclusion: Modifications to the standard medical and interventional algorithms may be required for mechanical thrombectomy in children.

Clinical significance: Referral centers specialized in pediatric neurology, pediatric anesthesia, and pediatric intervention are optimal for treating children using mechanical thrombectomy and for modifying the treatment, if required.

Keywords: Stroke; aspiration; children; stent; thrombectomy; thrombolysis.

Figure 1

Patient selection flowchart.

Figure 2

Preprocedural right carotid angiograms in anterior–posterior (AP) projection (a, b) reveal total occlusion of the right internal carotid artery (ICA) terminus. After recanalization of the supraclinoid ICA with aspiration thrombectomy (c), residual distal middle cerebral artery (MCA) and anterior cerebral artery (ACA) occlusions persist on the carotid angiogram (d). Both distal ACA (e, f) and distal MCA (g, h) occlusions were recanalized through stent retriever thrombectomy. Final AP (i) and lateral (j) carotid injections demonstrate the successful recanalization of the whole carotid artery territory. Diffusion-weighted image (k) and corresponding apparent diffusion coefficient (ADC) map (l) demonstrate acute infarction at the right basal ganglia. Follow-up magnetic resonance imaging (m, n) indicates regression of the diffusion restriction and consequent ADC pseudonormalization.