Basilar artery occlusion in a 14-year old female successfully treated with acute intravascular intervention: case report and review of the literature

Extended time window mechanical thrombectomy for pediatric acute ischemic stroke

Endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) remains an off-label procedure seldom utilized in the pediatric population; this holds especially true for patients presenting outside the standard 6-hour time window. In this review we describe the published literature regarding usage of the extended time window EVT in pediatric stroke. We searched PubMed for all pediatric AIS cases and case series that included patients treated with extended time window EVT. We found data from 38 cases found in 27 publications (15 case reports and 12 case series). The median age was 10 years; 60.5% males. The median NIHSS before EVT was 13 with a median time-to-treatment of 11 hours. The posterior circulation was involved in 50.0%. Stent retrievers were used in 68.5%, and aspiration in 13.2%. Angiographic outcome TICI ≥2B was achieved in 84.2%, whereas TICI˂2B was reported in 10.6%. A favorable clinical outcome (NIHSS score ≤4, modified Rankin score ≤1, or Pediatric Stroke Outcome measure score ≤1) occurred in 84.2%. Eight cases that did not report the clinical outcome employing a standardized scale described mild to absent neurological residual deficits. This study found data that supports that extended window EVT produces high recanalization rates and good clinical outcomes in pediatric patients with AIS. Nevertheless, the source materials are indirect and contain substantial inconsistencies with an increased risk of bias that amount to low evidence strength.

Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke.

METHODS

This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes.

RESULTS

Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge.

CONCLUSIONS

Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.

Endovascular clot retrieval for acute ischaemic stroke due to basilar artery occlusion in childhood

Endovascular clot retrieval (ECR) is an emerging therapy for treatment of acute ischaemic stroke (AIS) in adults, including basilar artery occlusion (BAO). Its role in children is not well established. We report four consecutive children with AIS due to BAO treated with ECR in Sydney, Australia. We reviewed the literature to characterize the 'natural course' of AIS due to BAO in children not treated with thrombolysis or ECR, and compared their outcome with our patients and reported children with BAO treated with ECR. Despite delays in diagnosis, ECR achieved recanalization in our four children. Three children had a good outcome (Paediatric Modified Rankin Score [PedmRS] 0-2). One child with acute leukaemia suffered recurrent basilar occlusion and died of brainstem dysfunction. Literature review identified 111 children exhibiting the natural course of AIS due to BAO, among whom 42% had good outcomes (PedmRS 0-2), 48% had significant residual disability (PedmRS 3-5), and 10% died. Of 34 children treated with ECR, 28 (82%) had good outcomes (PedmRS 0-2), five (15%) had significant residual disability (PedmRS 3-5), and one (3%) died. Complications of ECR were uncommon. These observations suggest ECR may be beneficial for children with AIS due to BAO. WHAT THIS PAPER ADDS: Children with acute ischaemic stroke (AIS) due to basilar artery occlusion (BAO) experience significant morbidity and mortality. Endovascular clot retrieval may be beneficial in children with AIS due to BAO.

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

OBJECTIVE

The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.

METHODS

Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).

RESULTS

The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.

CONCLUSIONS

Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

Childhood acute basilar artery thrombosis successfully treated with mechanical thrombectomy using stent retrievers: case report and review of the literature

INTRODUCTION

Acute basilar artery occlusion (ABAO) is an infrequent but potentially fatal cause of strokes in both adults and children, and it is usually due to vertebral artery dissection (VAD). VAD has been found to be usually a consequence of traumatic vertebral artery injury. ABAO usually presents with symptoms of acute ischemic stroke (AIS) of the posterior circulation or transient ischemic attack (TIA). It may lead to death or long-term disability if not promptly recanalized. Basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents.

CLINICAL PRESENTATION

We report the case of a 23-month old baby that came to the emergency room of our hospital for progressive impairment of consciousness associated with widespread stiffness and plaintive cry, appeared after accidental fall from stroller. An emergency brain CT scan was obtained showing multiple infarction lesions in the brainstem and left cerebellum suggestive of acute stroke in posterior circulation territories. An MR scan with angiography and diffusion-weighted sequences confirmed the multiple infarction lesions and demonstrated poor representation of the flow signal at the V3 segment of the left vertebral artery and absent representation of the flow signal at the distal segment of the basilar artery suggestive of acute thrombotic occlusion. The patient was immediately referred to interventional neuroradiology unit, and digital subtraction angiography showed complete basilar artery occlusion and left vertebral artery dissection at extracranial V2-V3 segment. The patient underwent intra-arterial thrombectomy using stent retrievers and occlusion of the V2-V3 segment of the left vertebral artery. The patient survived and long-term outcome was excellent.

CONCLUSIONS

To our knowledge, only nine cases of ABAO in children treated with intra-arterial thrombectomy have been previously reported in the literature. In only three cases, the Solitaire stent was applied. Our case is the first case of basilar artery occlusion treated with Solitaire stent, in a child under 24 months. The reports that are available so far indicate that basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents.

The efficiency analysis of thrombolytic rt-PA combined with intravascular interventional therapy in patients with acute basilar artery occlusion

In order to further optimize the treatment strategy for the patients with acute basilar artery occlusion, we were dedicated to study the therapeutic effects and influential factors in the process of treated basilar artery occlusion with thrombolytic combined vascular interventional therapy. 75 patients with acute basilar artery occlusion treated with arterial thrombolytic therapy were analyzed retrospectively. In accordance with the discharge records of patients, their short-term curative effect with 24-hour treatment and 14-days treatment were evaluated. Our data showed that the survival condition of the patients with acute acute basilar artery occlusion were visibly improved by combination thrombolytic and interventional therapy. Moreover, their BI scores were remarkably improved, while NIHSS and mRS scores were evidently reduced. These data proved that our treatment strategy was able to improve the survival condition of patients with acute basilar artery occlusion. Furthermore, our data showed that coagulation related factors remarkably improved in the patients, when they treated by combination thrombolytic therapy with interventional therapy. In addition, our results suggested that the patients' bilateral Babinski(+), revascularization and coma symptom were closely related to their prognosis after treated the patients with combination thrombolytic and vascular interventional therapy, and the difference was statistically significant (p<0.05, p<0.05, p<0.05). Besides, our data also displayed that the with stent assisted angioplasty was significantly superior to the patients with balloon angioplasty, and the difference was statistically significant (p<0.05). Anyhow, combination thrombolytic with interventional therapy can effectively promote the prognosis of the patients with acute basilar artery occlusion. The coma symptom, bilateral Babinski(+), and revascularization in the patients with acute basilar artery occlusion have an appreciable impact on the patients' prognosis.

Successful Manual Aspiration Thrombectomy in a Pediatric Patient

BACKGROUND

Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke. Furthermore, successful mechanical thrombectomy using a variety of techniques has been documented in numerous children and adolescents.

PATIENT DESCRIPTION

We present a 15-year-old boy with altered mental status and left hemiparesis due to acute ischemic stroke secondary to blockage of the right internal carotid artery terminus, most likely precipitated by end-stage heart failure and cardiac embolism. Mechanical aspiration thrombectomy using the Penumbra aspiration catheter without any adjunct surgical equipment or thrombolytic therapy was used to remove thrombus and treat the patient's acute ischemic stroke. He experienced complete artery recanalization with a Thrombolysis in Cerebral Infarction (TICI) score of 2C after the procedure. He also exhibited an 8 point improvement in his pediatric National Institutes of Health Stroke Scale score within 24 hours.

CONCLUSIONS

Mechanical aspiration thrombectomy is commonly used in adult hospitals but infrequently employed in pediatric patients with arterial ischemic stroke. Given its efficacy in our patient, we encourage a larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric patients with acute ischemic stroke.

Mechanical thrombectomy in pediatric acute ischemic stroke: Clinical outcomes and literature review

There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke.

Outcome Predictors in Acute Basilar Artery Occlusion

Objective:

To identify predictors of good outcome in acute basilar artery occlusion (BAO).

Background:

Acute ischemic stroke (AIS) caused by BAO is often associated with a severe and persistent neurological deficit and a high mortality rate.

Methods:

The set consisted of 70 consecutive AIS patients (51 males; mean age 64.5±14.5 years) with BAO. The role of the following factors was assessed: baseline characteristics, stroke risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, estimated time to therapy procedure initiation, treatment method, recanalization rate, change in neurological deficit, post-treatment imaging findings. 30- and 90-day outcome was assessed using the modified Rankin scale with a good outcome defined as a score of 0–3.

Results:

The following statistically significant differences were found between patients with good versus poor outcomes: mean age (54.2 vs. 68.9 years; p=0.0001), presence of arterial hypertension (52.4% vs. 83.7%; p=0.015), diabetes mellitus (9.5% vs. 55.1%; p=0.0004) and severe stroke (14.3% vs. 65.3%; p=0.0002), neurological deficit at time of treatment (14.0 vs. 24.0 median of National Institutes of Health Stroke Scale [NIHSS] points; p=0.001), successful recanalization (90.0% vs. 54.2%; p=0.005), change in neurological deficit (12.0 vs. 1.0 median difference of NIHSS points; p=0.005). Stepwise binary logistic regression analysis identified age (OR=0.932, 95% CI=0.882–0.984; p=0.012), presence of diabetes mellitus (OR=0.105, 95% CI=0.018–0.618; p=0.013) and severe stroke (OR=0.071, 95% CI=0.013–0.383; p=0.002) as significant independent negative predictors of good outcome.

Conclusions:

In the present study, higher age, presence of diabetes mellitus and severe stroke were identified as significant independent negative predictors of good outcome.

Successful mechanical thrombectomy in a 2-year-old male through a 4-French guide catheter

A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.

Childhood basilar artery occlusion: a report of 5 cases and review of the literature

Basilar artery occlusion has poor outcome in adults; little is known regarding outcomes in children. Whether intra-arterial treatments improve adult outcomes is controversial. Safety and efficacy of intra-arterial treatments in children are unknown. We report 5 cases of basilar artery occlusion and review published cases. We estimated National Institute of Health Stroke Scale (NIHSS) and modified Rankin Score (mRS) of published cases, compared scores between non-intra-arterial treatments and intra-arterial treatments groups, and examined the correlation between NIHSS and mRS. Of our cases, 4 had good outcomes and 1 died. Of 63 published cases, 45 had no intra-arterial treatments and 18 had intra-arterial treatments. In the non-intra-arterial treatments group 24 had good outcomes. In the intra-arterial treatments group 13 had good outcomes. There was strong correlation between the NIHSS and the mRS. Children with basilar artery occlusion have better outcomes than adults. Certain children with basilar artery occlusion may be treated conservatively. A registry for childhood basilar artery occlusion is urgently needed.

Acute ischemic stroke in a 12-year-old successfully treated with mechanical thrombectomy

We report the case of a healthy 12-year-old girl with an acute ischemic stroke successfully treated with mechanical thrombectomy. The child was referred to our hospital 6 hours after sudden onset of severe headache and left hemiparesis. Cerebral angiography findings were consistent with right distal internal carotid artery occlusion in addition to ipsilateral middle cerebral artery occlusion. Subsequent mechanical thrombectomy with Solitaire AB device resulted in complete vessel recanalization. The patient experienced progressive neurologic improvement with good clinical recovery at the 3-month follow-up. To our knowledge, only 3 cases of primary mechanical thrombectomy in children have been previously reported in the literature. Safety and efficacy data for endovascular therapies in pediatric acute ischemic stroke are lacking. We propose mechanical thrombectomy as an option in children with significant neurologic deficits and proven arterial occlusion, especially when the therapeutic window for intravenous thrombolysis has been exceeded.

Basilar Artery Thrombosis in a Child Treated With Intravenous Tissue Plasminogen Activator and Endovascular Mechanical Thrombectomy

Basilar artery occlusion in children is rare. It has a high mortality and morbidity if recanalization is not achieved before extensive brainstem infarction has occurred. An 11-year-old boy presented with a clinical and radiological "top-of-the-basilar" syndrome. Intravenous tissue plasminogen activator was administered, and the patient was immediately referred to the regional stroke center. Subsequent mechanical thrombectomy using a Solitaire stent (Solitaire FR stent; ev3, Irvine, CA, USA) resulted in clot removal and recanalization of the basilar artery 4 hours after stroke onset. The patient made a full clinical recovery. To the authors' knowledge this is the first report on basilar artery occlusion in a child treated with "bridging" therapy, the combination of intravenous thrombolysis and endovascular thrombectomy. If the diagnosis can be made within the time window for intravenous thrombolysis (4.5 hours), the present case suggests that bridging therapy in pediatric basilar artery occlusion can be safe and effective.

Basilar artery stroke in childhood

AIM

Little is known about basilar artery stroke (BAS) in children. The objective of this study was to calculate the incidence of BAS in children and to analyse the clinical presentation, risk factors, radiological findings, therapeutic approaches, and outcome of BAS in childhood.

METHOD

A prospective, population-based study including children with arterial ischaemic stroke and a systematic review of the literature was undertaken.

RESULTS

Seven children with BAS were registered at the Swiss Neuropaediatric Stroke Registry between January 2000 and June 2011 (incidence 0.037 per 100,000 children per year, 95% confidence interval [CI] 0.013-0.080). A further 90 cases were identified through the literature search. The majority of patients were male (73 males, 24 females) and the median age was 9 years (interquartile range [IQR]=6-13y). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score was 15 (IQR=4-27). Presenting signs and symptoms comprised impaired consciousness (n=64), quadri- or hemiparesis (n=58), bulbar dysfunction (n=46), vomiting, nausea (n=43), and headache (n=41). Prodromes occurred in 43% of cases. Aetiology was largely vasculopathic (n=38), but often unknown (n=40). Time to diagnosis varied from hours days; six patients received antithrombotic, thrombolytic, or mechanical endovascular treatment 12 hours or less after symptom onset. Outcome was good (modified Rankin Scale 0-2) in 45 patients; eight died. PedNIHSS score of up to 17 was a prognostic factor for good outcome.

INTERPRETATION

BAS is rare in children. Compared with adults, outcome is more favourable despite a considerable delay in diagnosis and treatment. Outcome was better in children with a PedNIHSS score of 17 or less.

Successful treatment of recurrent basilar artery occlusion with intra-arterial thrombolysis and vertebral artery coiling in a child

BACKGROUND

Signs of brainstem ischemia in children may be subtle, and outcome following basilar artery occlusion is often poor. There currently are no guidelines in children regarding the best methods to diagnose and treat basilar artery occlusion.

METHODS

Case report and literature review.

RESULTS

We describe the presentation and management of recurrent basilar artery occlusion in a previously healthy 5-year-old boy with vertebral artery dissection. Treatment included emergent intra-arterial tPA and mechanical thrombolysis of basilar artery clot, followed by later coiling of the vertebral artery to prevent recurring episodes of basilar artery ischemia.

CONCLUSION

Management of brainstem stroke in children requires coordination of neurology, critical care, and interventional radiology services. Delayed intra-arterial thrombolysis and vertebral artery coiling can be successfully used to treat basilar artery occlusion and prevent the recurrence of brainstem ischemia in children.