Kevin O’Connor, MD
International Stroke Conference 2021
March 17–19, 2021
The lack of evidence-based guidelines for endovascular thrombectomy (EVT) in children with acute ischemic stroke has forced institutions to develop their own policies and procedures based on trials in adults and limited pediatric studies. Lauzier et al. describe the framework of their pediatric EVT-capable practices in Seattle and St. Louis. Their joint ventures include co-located (connected structures; St. Louis) or nearby (Seattle) pediatric hospitals and adult comprehensive stroke centers that are guided by interdisciplinary teams comprising pediatric neurologists, radiologists, neurointerventionalists, anesthesiologists, and pediatric intensivists, among others.
Strong collaboration among the multidisciplinary group and advocacy for pediatric stroke patients are integral components of the programs. Their efforts led to formalized and streamlined workflows, including initial triaging of a pediatric stroke case, rapidly acquiring and reviewing imaging studies with MRI/MRA protocols prioritizing DWI and time-of-flight sequences, initiating acute interventions as needed (including intravenous alteplase), and consulting a neurointerventionalist using a pre-specified script. Candidates for pediatric EVT are selected based on consensus inclusion and exclusion criteria developed by the group.
For children who are deemed appropriate for EVT, a paging system alerts relevant providers, including anesthesiology, pediatric ICU, and nursing staff, among others. Co-located centers benefit from rapid in-house transport of the patient to an intervention suite, whereas separate facilities rely on expedited transfer by ambulance. Pediatric EVT occurs under general anesthesia, and the children are monitored in an ICU following the procedure. Close coordination with the adult comprehensive stroke centers allows the pediatric EVT teams to benefit from their experience caring for adults. Overlap between adult and pediatric EVT workflows allows for easy translation of process improvements from the adult to the pediatric program.
Although there are guidelines for managing pediatric stroke generally, robust, evidence-based guidelines for pediatric EVT and criteria for establishing and managing pediatric stroke centers are lacking.1 As such, providers will continue to rely on the reported experiences of colleagues to guide their own policies and procedures.
1. Ferriero DM, Fullerton HJ, Bernard TJ, Billinghurst L, Daniels SR, DeBaun MR, deVeber G, Ichord RN, Jordan LC, Massicotte P, et al.; American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing. Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke. 2019;50:e51-e96.