Thursday, December 5, 2019

Endovascular recanalization in childhood stroke

Sporns PB, Sträter R, Minnerup J, Wiendl H, Hanning U, Chapot R, Henkes H, Henkes E, Grams A, Dorn F, Nikoubashman O, Wiesmann M, Bier G, Weber A, Broocks G, Fiehler J, Brehm A, Psychogios M, Kaiser D, Yilmaz U, Morotti A, Marik W, Nolz R, Jensen-Kondering U, Schmitz B, Schob S, Beuing O, Götz F, Trenkler J, Turowski B, Möhlenbruch M, Wendl C, Schramm P, Musolino P, Lee S, Schlamann M, Radbruch A, Rübsamen N, Karch A, Heindel W, Wildgruber M, Kemmling A. Feasibility, Safety,and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study. JAMA Neurol. 2019 Oct 14. doi: 10.1001/jamaneurol.2019.3403. [Epub ahead of print]


Randomized clinical trials have shown the efficacy of thrombectomy of large intracranial vessel occlusions in adults; however, any association of therapy with clinical outcomes in children is unknown.

To evaluate the use of endovascular recanalization in pediatric patients with arterial ischemic stroke.

This retrospective, multicenter cohort study, conducted from January 1, 2000, to December 31, 2018, analyzed the databases from 27 stroke centers in Europe and the United States. Included were all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization. Median follow-up time was 16 months.

Endovascular recanalization.

The decrease of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission to day 7 was the primary outcome (score range: 0 [no deficit] to 34 [maximum deficit]). Secondary clinical outcomes included the modified Rankin scale (mRS) (score range: 0 [no deficit] to 6 [death]) at 6 and 24 months and rate of complications.

Seventy-three children from 27 participating stroke centers were included. Median age was 11.3 years (interquartile range [IQR], 7.0-15.0); 37 patients (51%) were boys, and 36 patients (49%) were girls. Sixty-three children (86%) received treatment for anterior circulation occlusion and 10 patients (14%) received treatment for posterior circulation occlusion; 16 patients (22%) received concomitant intravenous thrombolysis. Neurologic outcome improved from a median PedNIHSS score of 14.0 (IQR, 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7. Median mRS score was 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months. One patient (1%) developed a postinterventional bleeding complication and 4 patients (5%) developed transient peri-interventional vasospasm. The proportion of symptomatic intracerebral hemorrhage events in the HERMES meta-analysis of trials with adults was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40).

The results of this study suggest that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults; most of the treated children had favorable neurologic outcomes. This study may support clinicians' practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.

“This is a very optimistic time for pediatric stroke because these techniques of mechanical recanalization are so powerful in adults,” said Christine Fox, MD, MAS, co-author of an editorial published concurrently in JAMA Neurology and associate professor of neurology and director of the Pediatric Stroke and Cerebrovascular Disease Center at the University of California, San Francisco.

While she was enthusiastic about the investigation of recanalization in children, Dr. Fox and her co-author advised caution in interpreting long-term outcome measures from the Save ChildS research.

“Stroke recovery is heterogeneous in children at various stages of brain development, and the natural history of recovery may be good even in the absence of recanalization,” they wrote…

“If publication of the Save ChildS study raises awareness of pediatric stroke, the heightened attention would be a positive step toward encouraging the design of improved protocols to streamline diagnosis and deliver time-sensitive treatment,” said David Y. Huang, MD, PhD, FAHA, FAAN, FANA, professor and chief of the division of stroke and vascular neurology at the University of North Carolina at Chapel Hill.

“It's heartening because some data is better than the absence of data,” Dr. Huang said, allowing neurologists to feel more confident in recommending endovascular thrombectomy to parents of sick children now that there is data supporting the safety of the procedure. Furthermore, “in the absence of alternatives, most parents would agree to it,” he added…

Even in an era of advanced emergency medical services and improved public awareness of stroke, few pediatric patients arrive at hospitals within the optimal treatment window, said Dana D. Cummings, MD, PhD, associate professor of pediatrics and director of the pediatric stroke program at the University of Pittsburgh Medical Center's Children's Hospital of Pittsburgh.

“My hat is off to the centers that provided thrombectomy for these patients at the early time frame in the study, but that's going to be hard to replicate in most settings,” said Dr. Cummings, who would like to see a study looking at outcomes in children who present more than 4.5 hours after stroke onset and undergo mechanical recanalization…

The editorial also addressed special considerations for performing thrombectomy in children. It should ideally be undertaken by neurointerventional radiologists skilled in both pediatric endovascular procedures and stroke embolectomy to “guide selection of devices appropriate for the smaller cerebrovasculature in children.” However, “as stent retriever devices have been developed for embolectomy of more distal cerebral arteries, size may become less of a barrier in experienced hands. Caution remains advisable even early after stroke, particularly in young or small patients,” the authors wrote.

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