Kevin O’Connor, MD
Although there have been no large, robust, randomized trials of endovascular mechanical thrombectomy (EVT) in children with acute ischemic stroke, there is growing evidence indicating that the approach may be safe and effective.
van Es et al. performed EVT on 9 children between March 2014 and July 2017 (4 boys and 5 girls, aged 13 months-16 years, median 14 years) with an anterior circulation large vessel occlusion. Four of these children had a left ventricular assist device (ages 13 months, 18 months, 3 years, and 10 years). The median initial Pediatric National Institutes of Health Stroke Scale score (PedNIHSS) was 17 (IQR, 9.5-19.5). Four of 9 children received IV alteplase; four children with LVAD did not because they were therapeutically anticoagulated. Younger children with smaller vessels necessitated the use of smaller catheters and stent retrievers. The six children ages >10-year, however, underwent EVT with a stent retriever commonly employed for M1 occlusions in adults.
An adequate modified Treatment in Cerebral Infarction score (mTICI; 2B or better) was achieved in 8 of 9 children (mTICI 3; n=3, mTICI 2B; n=5) with a median of 2 attempts. Median PedNIHSS after EVT was 4 (IQR, 3-8.5), and 8 of 9 children had neurologic recovery within 24 hours after EVT. Although the five patients without an LVAD had good outcomes six months after EVT (modified Rankin Scale score 0-2), all four LVAD patients died from suspected complications associated with their underlying cardiomyopathy and LVAD rather than the EVT.
This analysis of data from the MR CLEAN registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) adds additional safety and efficacy data to the case reports/series and expert consensus that currently guides EVT in the pediatric population. Although young age and associated smaller vessel size may warrant special technical consideration, children often lack the tortuosity and atherosclerosis that can complicate EVT in adults. Devices commonly used in adults may be employed in older children. Comorbid cardiac conditions in children, especially the presence of an LVAD, may present unique challenges when considering EVT given their poor long-term prognosis.
