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Derrico NP, Kimball R, Weaver K, Strickland A. Mechanical Thrombectomy in Pediatric Large Vessel Occlusions Before Cerebrovascular Maturity: A Case Report and Technical Note. Cureus 2024; 16:e59027. [PMID: 38800193 PMCID: PMC11127794 DOI: 10.7759/cureus.59027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
Pediatric arterial ischemic stroke is a rare but increasingly acknowledged disorder. Large vessel occlusions in this population have been treated off-label with endovascular thrombectomy. However, there is limited evidence to guide management. Small children, before the age of five when the cerebrovasculature reaches adult size, present additional challenges. We report the case of cardioembolic basilar occlusion in a two-year-old and the technical details of endovascular management, currently lacking in published literature. We employed a 5 French slender sheath, typically used for radial access, as a femoral short sheath. We accessed the dominant vertebral artery with a 5 French intermediate catheter, navigated with a typical 0.027-inch microcatheter and 0.014-inch microwire, and performed direct aspiration thrombectomy of the basilar clot. No closure device was employed. The patient had a near-complete and durable recovery. Small children present additional challenges for the endovascular management of stroke. Pre-procedural imaging can be used to design an aspiration-capable system appropriate for the child's size. Endovascular thrombectomy in children is feasible with some modifications to adult protocols.
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Affiliation(s)
| | - Rebekah Kimball
- Neurosurgery, University of Mississippi Medical Center, Jackson, USA
| | - Kristin Weaver
- Neurosurgery, University of Mississippi Medical Center, Jackson, USA
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Bandlamuri S, Custozzo A, Silva J, Bandlamuri SK, Qian J, Paul AR. Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism. World Neurosurg 2024; 183:e761-e771. [PMID: 38211812 DOI: 10.1016/j.wneu.2024.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Stroke presentation secondary to a cardiac myxoma thromboembolism is rare in the pediatric population. Because of such rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with the classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with strokelike symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. METHODS We performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n = 2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. RESULTS The most common imaging modality was magnetic resonance imaging in 42% of cases, computed tomography in 36.8%, followed by computed tomography angiography in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n = 7). CONCLUSIONS We describe an urgent mechanical thrombectomy and share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.
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Affiliation(s)
- Sruti Bandlamuri
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Amanda Custozzo
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Jonathan Silva
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | | | - Jiang Qian
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA.
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3
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Pearl MS, Tsuchida TN, Oluigbo C, Kratimenos P, Anwar T, Kousa Y, Gaillard WD, Chang T. Definitive treatment of seizures due to hemimegalencephaly in neonates and young infants by transarterial embolization: technical considerations for 'endovascular embolic hemispherectomy'. J Neurointerv Surg 2023; 16:81-87. [PMID: 36302639 DOI: 10.1136/jnis-2022-019049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This case series describes the technical considerations and effectiveness of 'endovascular embolic hemispherectomy' for the treatment of medically intractable seizures in neonates and young infants with hemimegalencephaly (HME) and in whom surgical hemispherectomy is not a viable option. METHODS This is a descriptive review of the endovascular technique used to treat consecutive pediatric patients with serial transarterial embolization for intractable seizures due to HME between 2018 and 2022. Clinical presentation, endovascular procedural details and complications, and efficacy were examined. RESULTS Three infants (13-day-old, 13-week-old and 15-day-old) with HME and intractable seizures underwent a total of 10 transarterial embolizations. Anticipated intraprocedural events included vasospasm and focal subarachnoid hemorrhage in all three infants, effectively controlled endovascularly, and non-target embolization in one infant. No infants had symptomatic intracranial hemorrhage or femoral artery occlusion. EEG background quiescence and seizure cessation was achieved after the final stage of embolization in all patients. All infants were discharged home from the neonatal ICU (median length of stay 36 days, range 27-74 days) and remain seizure-free to date (4 years, 9 months, and 8 months). None have developed hydrocephalus, required surgical hemispherectomy or other neurosurgical interventions. CONCLUSION Endovascular hemispherectomy can be safely used to provide definitive treatment of HME-related epilepsy in neonates and young infants when intraprocedural events are managed effectively. This less invasive novel approach should be considered a feasible early alternative to surgical hemispherectomy. Further studies are needed to enhance the safety profile and to assess long-term neurodevelopmental outcome and durability of freedom from seizures.
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Affiliation(s)
- Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA
- Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tammy N Tsuchida
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima Oluigbo
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Children's National Health System, Washington, District of Columbia, USA
| | - Panagiotis Kratimenos
- Neonatology, Children's National Hospital, Washington, District of Columbia, USA
- Neonatology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Tayyba Anwar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Youssef Kousa
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - William D Gaillard
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
- Neurology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Pero G, Ruggieri F, Macera A, Piano M, Gladin CR, Motto C, Cervo A, Chieregato A. Endovascular treatment of acute ischemic stroke in childhood: A comprehensive literature review based on the experience of a single center. Eur J Radiol Open 2023; 11:100528. [PMID: 37840654 PMCID: PMC10569978 DOI: 10.1016/j.ejro.2023.100528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/24/2023] [Accepted: 09/30/2023] [Indexed: 10/17/2023] Open
Abstract
Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood. The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS. The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children. The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points. The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise. Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.
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Affiliation(s)
- Guglielmo Pero
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Ruggieri
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Caroline Regna Gladin
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Motto
- Neurology Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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5
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Bilgin C, Ibrahim M, Azzam AY, Ghozy S, Elswedy A, Kobeissi H, Sobhi Jabal M, Kadirvel R, Boulouis G, Naggara O, Fiehler J, Psychogios M, Lee S, Wildgruber M, Kemmling A, Al-Mufti F, Kossorotoff M, Sporns PB, Kallmes DF. Mechanical Thrombectomy for Pediatric Large Vessel Occlusions : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:635-644. [PMID: 36592199 DOI: 10.1007/s00062-022-01246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/22/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Acute intracranial large vessel occlusion (LVO) is an important cause of morbidity and mortality among children; however, unlike in adults, no clinical trial has investigated the benefit of mechanical thrombectomy (MT) in pediatric LVO. Thus, MT remains an off-label procedure for pediatric stroke. PURPOSE To investigate the efficacy and safety of MT in pediatric LVO. METHODS A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies reporting safety and efficacy outcomes for endovascular treatment of pediatric LVO were included. Data regarding recanalization, functional outcome, symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. Functional outcome was assessed with the modified Rankin scale (mRS). A fixed or random-effects model was used to calculate pooled event rates and 95% confidence intervals (CI). RESULTS In this study 11 studies comprising 215 patients were included. The successful recanalization rate was 90.3% (95% CI = 85.77-95.11%), and complete recanalization was achieved in 52.7% (95% CI = 45.09-61.62%) of the cases. The favorable (mRS = 0-2) and excellent (mRS = 0-1) outcome rates were 83.3% (95% CI = 73.54-94.50%) and 59.5% (95% CI = 44.24-80.06%), respectively. The overall sICH prevalence was 0.59% (95% CI = 0-3.30%) and mortality rate was 3.2% (95% CI = 0.55-7.38%). CONCLUSION In our meta-analysis, MT demonstrated a promising safety and efficacy profile for pediatric patients, with consistently high efficacy outcomes and low complication rates. Our results support the utilization of MT in pediatric LVOs; however, prospective studies are still needed to further establish the role of pediatric MT as a first-line treatment strategy.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | | | - Ahmed Y Azzam
- Faculty of Medicine, October 6 University, 6th of October City, Egypt
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Adam Elswedy
- Uppsala University Faculty of Medicine, Uppsala, Sweden
| | - Hassan Kobeissi
- College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA
| | | | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Grégoire Boulouis
- Department of Neuroradiology, Université de Tours, CHRU Bretonneau, Tours, France
- French Center for Pediatric Stroke, Pediatric Neurology, APHP-University Hospital Necker-Enfants malades, Paris, France
| | - Olivier Naggara
- Department of Neuroradiology, Université de Paris City, INSERM U1266, GHU Paris, Sainte-Anne Hospital, Paris, France
- French Center for Pediatric Stroke, Pediatric Neurology, APHP-University Hospital Necker-Enfants malades, Paris, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Radiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Sarah Lee
- Stanford Stroke Center, Stanford University, Palo Alto, CA, USA
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Manoelle Kossorotoff
- French Center for Pediatric Stroke, Pediatric Neurology, APHP-University Hospital Necker-Enfants malades, Paris, France
| | - Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
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Bhatia KD, Chowdhury S, Andrews I, Goetti R, Webster R, Troedson C, Dale RC, Muthusami P, Parra-Farinas C, Dlamini N, Moharir M, Miteff C, Miteff F, Worthington J, Tastula K, Ang T, Briest R, Pulcine E. Association Between Thrombectomy and Functional Outcomes in Pediatric Patients With Acute Ischemic Stroke From Large Vessel Occlusion. JAMA Neurol 2023; 80:910-918. [PMID: 37486670 PMCID: PMC10366944 DOI: 10.1001/jamaneurol.2023.2303] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/12/2023] [Indexed: 07/25/2023]
Abstract
Importance Pediatric large vessel occlusion (LVO) stroke has a poor natural history. However, uptake of mechanical thrombectomy is hindered by a lack of clinical trial data in children. A randomized clinical trial is not feasible due to small sample sizes and absence of equipoise. Objective To evaluate whether pediatric patients with acute LVO stroke who undergo thrombectomy have better clinical outcomes than matched patients managed conservatively. Design, Setting, and Participants This matched case-control study used pooled stroke registry data from 5 tertiary referral hospitals in Australia and Canada from January 2011 to April 2022. Patients were aged 1 month to younger than 18 years with acute LVO stroke. Pooled data identified 31 thrombectomy patients and 46 control patients. Five patients undergoing thrombectomy with basilar artery occlusion were excluded due to insufficient controls. Using a hierarchal matching system (site of occlusion, age group, side of occlusion, and sex), deidentified consensus matching of patients and controls was undertaken while blinded to clinical outcome. Data were analyzed from July to November 2022. Exposure In the case cohort, mechanical thrombectomy was undertaken for management of acute LVO stroke. The control cohort received medical treatment only. Main Outcomes and Measures The primary outcome was the functional clinical status 3 months following stroke, measured by the pediatric modified Rankin Scale (mRS). Clinical outcomes were compared between groups using ordinal regression analysis. Results Of 52 included patients, 31 (60%) were male, and the mean (SD) age was 10.3 (4.4) years. Matching was achieved for 26 children undergoing thrombectomy with 26 controls. There was no significant difference between groups for site or side of occlusion, age, sex, etiology, thrombolysis status, baseline Alberta Stroke Programme Early CT Score, or time since last seen well to presentation. Patients undergoing thrombectomy had superior clinical outcomes than control patients at 3 months on the pediatric mRS (odds ratio, 3.76; 95% CI, 1.32-10.67; P = .01). These superior outcomes were maintained at final follow-up (odds ratio, 3.65; 95% CI, 1.25-10.68; P = .02). Conclusions and Relevance In the absence of a randomized clinical trial, this case-control study demonstrates better clinical outcomes with thrombectomy than medical management alone for pediatric patients aged 2 to 18 years with anterior circulation LVO stroke.
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Affiliation(s)
- Kartik D. Bhatia
- Department of Medical Imaging, Children’s Hospital at Westmead, Westmead, Australia
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Samyami Chowdhury
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ian Andrews
- Department of Neurology, Sydney Children’s Hospital, Randwick, Australia
| | - Robert Goetti
- Department of Medical Imaging, Children’s Hospital at Westmead, Westmead, Australia
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Richard Webster
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- T.Y. Nelson Department of Neurology and Neurosurgery, Children’s Hospital at Westmead, Westmead, Australia
| | - Christopher Troedson
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- T.Y. Nelson Department of Neurology and Neurosurgery, Children’s Hospital at Westmead, Westmead, Australia
| | - Russell C. Dale
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- T.Y. Nelson Department of Neurology and Neurosurgery, Children’s Hospital at Westmead, Westmead, Australia
| | - Prakash Muthusami
- Division of Image-Guided Therapy, Department of Radiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carmen Parra-Farinas
- Division of Image-Guided Therapy, Department of Radiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mahendra Moharir
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Miteff
- Department of Neurology, John Hunter Children’s Hospital, Newcastle, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Kylie Tastula
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Timothy Ang
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Romain Briest
- Department of Neurology, Sydney Children’s Hospital, Randwick, Australia
- The Neurology and Clinical Neurophysiology Department, Women’s and Children’s Hospital, Adelaide, Australia
| | - Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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Requejo F, Teplisky D, Dutra MLG, Mouratian DM, Kikano R, Nguyen TN, Abdalkader M. Pediatric Interventional Neuroradiology. Semin Neurol 2023; 43:408-418. [PMID: 37536373 DOI: 10.1055/s-0043-1771511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Pediatric neurovascular disorders can lead to substantial mortality and morbidity if not diagnosed early and adequately managed. Children with neurovascular diseases cannot be treated as small adults as the vascular and central nervous system anatomy, physiology, and pathologies in children differ greatly from those of adults. In addition, some neurovascular pathologies are seen exclusively in children such as aneurysmal malformation of the vein of Galen, pial fistulas, and dural fistulas in the context of dural sinus disease. In this review, we aim to present an overview of the common pediatric neurovascular diseases along with their endovascular management.
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Affiliation(s)
- Flavio Requejo
- Department of Pediatric Interventional Neuroradiology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - Dario Teplisky
- Department of Pediatric Interventional Radiology, Vascular Anomalies Interdisciplinary Group, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | - María Laura González Dutra
- Department of Pediatric Interventional Neuroradiology, Hospital de Pediatría Prof. Dr. Juan P Garrahan, Buenos Aires, Argentina
| | | | - Raghid Kikano
- Department of Radiology, Lebanese American University-Gilbert and Rose Mary Chagoury School of Medicine, Beirut, Lebanon
- Department of Radiology, CISS de l'Abitibi-Temiscamingues, Québec, Canada
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Mohamad Abdalkader
- Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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8
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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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9
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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10
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Endovascular treatment of pediatric basilar artery aneurysms: case series and literature review. Childs Nerv Syst 2023; 39:25-34. [PMID: 36318284 DOI: 10.1007/s00381-022-05728-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 02/28/2023]
Abstract
PURPOSE Pediatric basilar artery aneurysms are rare and challenging to treat. Microsurgical options and standard endovascular coiling are often undesirable choices for treatment of this pathology. Additional endovascular strategies are needed. METHODS Presentation, diagnosis, and management of pediatric basilar aneurysms were reviewed, with an emphasis on endovascular treatment strategies. Our case series of 2 patients was presented in detail, one treated with flow diversion and vessel sacrifice and one treated with stent-assisted coiling. An extensive review of the literation was performed to find other examples of pediatric basilar artery aneurysms treated with endovascular techniques. RESULTS Twenty-nine studies met inclusion criteria. Fifty-nine aneurysms in 58 patients were treated using endovascular techniques. Mortality rate was 10.3% (6/58) and a poor outcome (GOS 1-3) occurred in 15.5% (9/58). There were 4 reported recurrences requiring retreatment; however, only 46.5% of patients had reported follow-up of at least 1 year. 71.1% (42/59) were dissecting aneurysms. CONCLUSION Basilar artery aneurysms in the pediatric population are rare, commonly giant and fusiform, and often not amenable to microsurgical or coiling techniques. The surrounding vasculature, location, size, and morphology of the aneurysm along with the durability of treatment must be considered in treatment decisions. With proper patient selection, stent-assisted coiling and flow diversion may increase the durability and safety of endovascular treatment in this population.
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11
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Rodríguez-López A, Gimeno I, Vila S, Seoane A, Ballenilla F, Ramos A, Hilario A, Núñez N, Camacho A, Simón R. Mechanical Thrombectomy for Acute Stroke in a 2-Month-Old Patient and Review of the Literature in Infancy. Neuropediatrics 2022; 53:376-380. [PMID: 35512844 DOI: 10.1055/a-1844-8780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Mechanical thrombectomy (MT) in pediatric stroke is supported by studies in adults, but there is controversy regarding younger patients. The main growth of intracranial vessels occurs up to 2 years when there can be more difficulties in MT.Description of the MT performed in a 2-month-old patient-the youngest infant published to date. We also review the literature on MT for stroke in infants.A 2-month-old patient presented with an awakening stroke secondary to an occlusion of the M1 segment of the left middle cerebral artery. A successful MT was performed with an aspiration device without clinically significant complications. An etiological study was completed, and neuroimaging showed focal cerebral arteriopathy. The 3-month outcome was excellent: the pediatric modified Rankin score was 0.Including this case, MT for acute stroke has been reported in only 10 infants. MT was successful in 90%, mostly using adult conventional stent retrievers. There were complications only in patients with mechanical circulatory support (MCS) devices; three patients died due to hemorrhagic transformation after MT and one patient died due to recurrent ischemic stroke.MT seems effective and safe in infants similarly to other pediatric ages. In children under 2 years of age, the presence of comorbidities requiring MCS devices is the main factor underlying poor prognosis.
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Affiliation(s)
| | - Isabel Gimeno
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sara Vila
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Andrea Seoane
- Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Federico Ballenilla
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Ramos
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amaya Hilario
- Department of Radiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Noemí Núñez
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Camacho
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rogelio Simón
- Department of Neurology, Hospital Universitario 12 de Octubre, Madrid, Spain
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12
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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13
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Taylor JM, Chang M, Vaughan J, Horn PS, Zhang B, Leach JL, Vadivelu S, Abruzzo T. Cerebral Arterial Growth in Childhood. Pediatr Neurol 2022; 134:59-66. [PMID: 35839526 DOI: 10.1016/j.pediatrneurol.2022.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/22/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Improved understanding of cerebral arterial growth in children may lead to advances in the diagnosis and treatment of pediatric cerebrovascular disease. We correlated cross-sectional diameters of major cerebral arterial structures with age, sex, head circumference, weight, and height in children without cerebrovascular disease. METHODS Children with normal brain magnetic resonance imaging (MRI) were retrospectively identified and stratified into 23 age cohorts from birth to age 18 years. Absence of vascular disease was verified by medical record review. Demographic and biometric data were obtained from medical records. Intracranial arterial diameter (IAD) was measured on T2-weighted fast spin echo brain MRI of vertebral, basilar, internal carotid artery, and circle of Willis arterial segments. RESULTS A total of 307 subjects are included in the analysis, including 5833 vessel segments (mean age 8.4 years, 53% female). Indications for imaging were headache (73%), seizure (26%) and concussion (1%). IAD rapidly increased during the first year of life (mean growth velocity 0.064 to 0.213 mm/month) and then plateaued or slightly decreased between age one and 18 years (mean growth velocity -0.002 to 0.003 mm/month). Multivariable analysis shows strongest correlation with head circumference as a predictor of IAD. Weaker correlations are associated with weight and age. Height and sex are not well correlated with IAD. CONCLUSIONS Intracranial arteries grow rapidly during the first year of life and then sharply plateau or slightly decrease in luminal diameter between infancy and early adulthood. IAD is more closely correlated with head circumference than age.
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Affiliation(s)
- J Michael Taylor
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio.
| | - Michael Chang
- Division of Ophthalmology, West Virginia University, School of Medicine, Morgantown, West Virginia
| | - Jessica Vaughan
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bin Zhang
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James L Leach
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sudhakar Vadivelu
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Medical Group, Phoenix, Arizona; Mayo Clinic College of Medicine, Phoenix, Arizona; University of Arizona, College of Medicine, Phoenix, Arizona
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14
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Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, Hanft S, Bowers C, Yaghi S, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke. Stroke 2022; 53:1530-1539. [PMID: 35272483 DOI: 10.1161/strokeaha.121.036361] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence regarding the utilization and outcomes of endovascular thrombectomy (EVT) for pediatric ischemic stroke is limited, and justification for its use is largely based on extrapolation from clinical benefits observed in adults. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify pediatric patients with ischemic stroke (<18 years old) during the period of 2010 to 2019. Complex samples statistical methods were used to characterize the profiles and clinical outcomes of EVT-treated patients. Propensity adjustment was performed to address confounding by indication for EVT based on disparities in baseline characteristics between EVT-treated patients and those medically managed. RESULTS Among 7365 pediatric patients with ischemic stroke identified, 190 (2.6%) were treated with EVT. Utilization significantly increased in the post-EVT clinical trial era (2016-2019; 1.7% versus 4.0%; P<0.001), while the use of decompressive hemicraniectomy decreased (2.8% versus 0.7%; P<0.001). On unadjusted analysis, 105 (55.3%) EVT-treated patients achieved favorable functional outcomes at discharge (home or to acute rehabilitation), while no periprocedural iatrogenic complications or instances of contrast-induced kidney injury were reported. Following propensity adjustment, EVT-treated patients demonstrated higher absolute but nonsignificant rates of favorable functional outcomes in comparison with medically managed patients (55.3% versus 52.8%; P=0.830; adjusted hazard ratio, 1.01 [95% CI, 0.51-2.03]; P=0.972 for unfavorable outcome). Among patients with baseline National Institutes of Health Stroke Scale score >11 (75th percentile of scores in cohort), EVT-treated patients trended toward higher rates of favorable functional outcomes compared with those treated medically only (71.4% versus 55.6%; P=0.146). In a subcohort assessment of EVT-treated patients, those administered preceding thrombolytic therapy (n=79, 41.6%) trended toward higher rates of favorable functional outcomes (63.3% versus 49.5%; P=0.060). CONCLUSIONS This cross-sectional evaluation of the clinical course and short-term outcomes of pediatric patients with ischemic stroke treated with EVT demonstrates that EVT is likely a safe modality which confers high rates of favorable functional outcomes.
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Affiliation(s)
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Carrie R Muh
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Michael Tobias
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Avinash Mohan
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Philip Overby
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (S.Y.)
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.).,Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
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15
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Dalai S, Limaye U, Kolli S, Maturu MVS, Narayana RV, Pati R, Korada SK, Vankineni K, Sameera A, Datla AV. Endovascular Treatment of Acute Ischemic Stroke in Patients Younger than 18 Years. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1740568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractRapid and effective revascularization is very important in the treatment of acute ischemic stroke (AIS). Endovascular treatment is a promising modality in the management of AIS in young patients. We evaluated the clinical and imaging records in 14 patients younger than 18 years presenting within 6 hours of AIS. They received endovascular therapy (ET) either by mechanical thrombectomy, thromboaspiration, or both (Solumbra) between July 2017 and June 2021 in our institute. The National Institute of Health Stroke Scale (NIHSS) score was calculated on admission and before the discharge of all patients. The 90-day modified Rankin Scale (mRS) score on disability-free outcome was also evaluated. The mean preprocedure NIHSS score was 10.78 ± 2.11 that improved to 4.5 ± 1.88 after the procedure. Thrombolysis in cerebral infarction (TICI) grade 2b and 3 blood flow could be established in 12 (85.72%) patients. One patient had TICI 2a flow and one patient had recurrent occlusion despite repeated recanalization (TICI grade 0). The disability-free outcome, mRS score at 90 days was 0 to 1 in 12 (85.72%) patients, mRS score 2 in one (7.14%) patient, and mRS score 3 in one patient (7.14%). We did not have any major complication related to the procedure. ET provides high rates of arterial recanalization and favorable disability-free outcomes in young patients with AIS.
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Affiliation(s)
- Sibasankar Dalai
- Department of Interventional Neuroradiology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Uday Limaye
- Department of Neurointervention, Lilavati Hospital, Mumbai, Maharashtra, India
| | - Satyarao Kolli
- Department of Neurology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | | | | | - Rajesh Pati
- Department of Neurology, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Suresh Kumar Korada
- Department of Neurology, Seven Hills Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Kuchelababu Vankineni
- Department of Anaesthesiology and Critical Care, Seven Hills Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Anantamakula Sameera
- Department of Radiodiagnosis, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Aravind Varma Datla
- Department of Internal Medicine, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
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16
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Gadgil N, Aldave G, Whitehead WE, Dmytriw AA, Chen K, Orbach D, Maier I, Behme D, Fargen KM, Elijovich L, Dornbos D, Spiotta A, Kan P. Endovascular Intervention for Refractory Pediatric Cerebral Venous Sinus Thrombosis. Pediatr Neurol 2021; 121:45-50. [PMID: 34147818 DOI: 10.1016/j.pediatrneurol.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/18/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare but potentially morbid disease in the pediatric population, and the optimal treatment is not fully understood. Endovascular intervention for this condition has been rarely reported. METHODS The Stroke Thrombectomy and Aneurysm Registry was queried for patients aged less than or equal to 18 years undergoing endovascular treatment for CVST in the past 10 years. Clinical charts and radiographic data were retrospectively reviewed. Modified Rankin Score (mRS) at 90 days postprocedure was determined as the primary outcome. RESULTS A total of seven patients across five pediatric centers ranging from 7 to 16 years of age were identified with a mean follow-up of 28 months. All had underlying conditions predisposing to CVST. Endovascular intervention was undertaken due to neurological deterioration despite systemic anticoagulation; venous infarct was evident preoperatively in six of seven patients. Mechanical venous thrombectomy was attempted in all individuals, and intrasinus thrombolytic therapy was also performed in three cases. Six patients had favorable outcome with mRS 0 or 1 at 90 days postprocedure; one remained neurologically devastated. CONCLUSIONS Endovascular treatment by an experienced interventionalist may be safe and effective in severe cases of CVST in children failing frontline therapy. Children with radiographic or clinical progression despite anticoagulation may be considered for endovascular intervention in a timely manner.
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Affiliation(s)
- Nisha Gadgil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Guillermo Aldave
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine/ Texas Children's Hospital, Houston, Texas
| | - Adam A Dmytriw
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Karen Chen
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Darren Orbach
- Department of Neurointerventional Radiology, Boston Children's Hospital/ Harvard Medical School, Boston, Massachusetts
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Caroline
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas.
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17
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Gailloud P, Pearl MS. Endovascular therapy for acute stroke in children: age and size technical limitations. J Neurointerv Surg 2021; 13:794-798. [PMID: 33832970 DOI: 10.1136/neurintsurg-2021-017311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
Endovascular therapies for acute childhood stroke remain controversial and little evidence exists to determine the minimum age and size cut-off for thrombectomy in children. Despite this, an increasing number of reports suggest feasibility of thrombectomy in at least some children by experienced operators. When compared with adults, technical modifications may be necessary in children owing to differences in vessel sizes, tolerance of blood loss, safety of contrast and radiation exposure, and differing stroke etiologies. We review critical considerations for neurologists and neurointerventionalists when treating pediatric stroke with endovascular therapies. We discuss technical factors that may limit feasibility of endovascular therapy, including size of the femoral and cervicocerebral arteries, which contributes to vasospasm risk. The risk of femoral vasospasm can be assessed by comparing catheter outer diameter with estimated femoral artery size, which can be estimated based on the child's height. We review evidence supporting specific strategies to mitigate cervicocerebral arterial injury, including technique (stent retrieval vs direct aspiration) and device size selection. The importance of and strategies for minimizing blood loss, radiation exposure, and contrast administration are reviewed. Attention to these technical limitations is critical to delivering the safest possible care when thrombectomy is being considered for children with acute stroke.
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Affiliation(s)
- Lisa R Sun
- Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana Harrar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Gerald Drocton
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Philippe Gailloud
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA.,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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18
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Schwarz J, Al Balushi A, Sundararajan S, Dinkin M, Oliveira C, Greenfield JP, Patsalides A. Management of idiopathic intracranial hypertension in children utilizing venous sinus stenting. Interv Neuroradiol 2021; 27:257-265. [PMID: 33236688 PMCID: PMC8050535 DOI: 10.1177/1591019920976234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/21/2020] [Accepted: 10/01/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Venous sinus stenting (VSS) is an accepted and minimally invasive treatment for adult idiopathic intracranial hypertension (IIH) associated with lateral sinus stenosis (LSS). The efficacy and safety of venous sinus stenting (VSS) in children with IIH has not been established. METHODS This is a retrospective analysis of IIH patients 18 years of age or younger with LSS treated with VSS at our institution. Included patients have fulminant disease course or are refractory or intolerant to medical management. RESULTS Eight patients were identified; 4 males and 4 females. Mean age is 13.4 years (range 4-18). All patients had severe headaches, 5 had blurred vision, 3 had diplopia and 3 had pulsatile tinnitus. Papilledema was present in 4 patients. Three patients had prior surgical procedures. Four patients were intolerant to medical management, 3 were refractory and 1 had fulminant course. Cerebral venography demonstrated severe stenosis of the dominant sinus in 6 patients and of bilateral co-dominant sinuses in 2 patients. Six patients had intrinsic stenosis and 2 had extrinsic stenosis. Venous sinus stenting (VSS) resulted in improvement of symptoms, papilledema and normalization of CSF opening pressure in 7 patients. No immediate complications were observed. Mean follow-up period is 21 months (range 6-42). Two patients required re-stenting; one responded well and the other had persistent symptoms and underwent subsequent surgical procedures of CSF diversion, suboccipital decompression and duraplasty which were also ineffective. CONCLUSION VSS may provide a viable option for pediatric IIH patients who are intolerant to medication, have failed conservative management or prior surgical interventions, or present with fulminant disease.
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Affiliation(s)
- Justin Schwarz
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Ali Al Balushi
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Sri Sundararajan
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Marc Dinkin
- Department of Ophthalmology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Athos Patsalides
- Department of Neurological Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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19
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Stroh JN, Bennett TD, Kheyfets V, Albers D. Clinical Decision Support for Traumatic Brain Injury: Identifying a Framework for Practical Model-Based Intracranial Pressure Estimation at Multihour Timescales. JMIR Med Inform 2021; 9:e23215. [PMID: 33749613 PMCID: PMC8077603 DOI: 10.2196/23215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The clinical mitigation of intracranial hypertension due to traumatic brain injury requires timely knowledge of intracranial pressure to avoid secondary injury or death. Noninvasive intracranial pressure (nICP) estimation that operates sufficiently fast at multihour timescales and requires only common patient measurements is a desirable tool for clinical decision support and improving traumatic brain injury patient outcomes. However, existing model-based nICP estimation methods may be too slow or require data that are not easily obtained. OBJECTIVE This work considers short- and real-time nICP estimation at multihour timescales based on arterial blood pressure (ABP) to better inform the ongoing development of practical models with commonly available data. METHODS We assess and analyze the effects of two distinct pathways of model development, either by increasing physiological integration using a simple pressure estimation model, or by increasing physiological fidelity using a more complex model. Comparison of the model approaches is performed using a set of quantitative model validation criteria over hour-scale times applied to model nICP estimates in relation to observed ICP. RESULTS The simple fully coupled estimation scheme based on windowed regression outperforms a more complex nICP model with prescribed intracranial inflow when pulsatile ABP inflow conditions are provided. We also show that the simple estimation data requirements can be reduced to 1-minute averaged ABP summary data under generic waveform representation. CONCLUSIONS Stronger performance of the simple bidirectional model indicates that feedback between the systemic vascular network and nICP estimation scheme is crucial for modeling over long intervals. However, simple model reduction to ABP-only dependence limits its utility in cases involving other brain injuries such as ischemic stroke and subarachnoid hemorrhage. Additional methodologies and considerations needed to overcome these limitations are illustrated and discussed.
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Affiliation(s)
- J N Stroh
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States
| | - Tellen D Bennett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Vitaly Kheyfets
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States
| | - David Albers
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
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20
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Beslow LA, Lo WD. Key Metrics Are Required to Refine Guidelines for Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1222-1224. [PMID: 33719514 DOI: 10.1161/strokeaha.120.033561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren A Beslow
- Departments of Neurology and Pediatrics, Division of Child Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (L.A.B.)
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Division of Child Neurology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus (W.D.L.)
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21
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Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke 2021; 52:1213-1221. [PMID: 33719517 DOI: 10.1161/strokeaha.120.032009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Aurora (M.B.)
| | - Dwight Barry
- Clinical Analytics (D.B.), Seattle Children's Hospital
| | - Akash P Kansagra
- Departments of Radiology, Neurological Surgery, and Neurology, Washington University School of Medicine in St Louis (A.P.K.)
| | - Danial Hallam
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle (D.H.)
| | - Michael Abraham
- Departments of Neurology and Interventional Radiology, University of Kansas Medical Center (M.A.)
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22
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Fragata I, Morais T, Silva R, Nunes AP, Loureiro P, Diogo Martins J, Pamplona J, Carvalho R, Baptista M, Reis J. Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature. Interv Neuroradiol 2021; 27:16-24. [PMID: 32903115 PMCID: PMC7903541 DOI: 10.1177/1591019920958827] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/18/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy is standard treatment for large vessel occlusion (LVO) in adults. There are no randomized controlled trials for the pediatric population. We report our single-center experience with thrombectomy of LVO in a series of pediatric patients, and perform a review of the literature. METHODS Retrospective review of consecutive pediatric thrombectomy cases between 2011 and 2018. Demographic variables, imaging data, technical aspects and clinical outcome were recorded. RESULTS In a period of 7 years, 7 children were treated for LVO at our center. Median age was 13 (2-17), and median Ped-NIHSS was 15 (3-24), and the median ASPECTS was 8 (2-10). Five patients had cardiac disease, and 2 of them were under external cardiac assistance. Median time from onset of symptoms to beginning of treatment was 7h06m (2h58m-21h38m). Five patients had middle cerebral artery occlusions. Thrombectomy was performed using a stentriever in 3 patients, aspiration in 3 patients, and combined technique in 1 patient. Six patients had good recanalization (TICI 2 b/3). There were no immediate periprocedural complications. At 3 months, 4 patients (57%) were independent (mRS score <3). Two patients died, one after haemorrhagic transformation of an extensive MCA infarct, and one due to extensive brainstem ischemia in the setting of varicella vasculitis. DISCUSSION Selected pediatric patients with LVO may be treated with mechanical thrombectomy safely. In patients under external cardiac assistance and under anticoagulation, thrombectomy is the only alternative for treatment of LVO. A multidisciplinary approach in specialized pediatric stroke centers with trained neurointerventionalists are essential for good results.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Teresa Morais
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rita Silva
- Pediatric Neurology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Universitário Lisboa Central,
Lisboa, Portugal
| | - Petra Loureiro
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - José Diogo Martins
- Pediatric Cardiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Jaime Pamplona
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Rui Carvalho
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - Mariana Baptista
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
| | - João Reis
- Neuroradiology Department, Centro Hospitalar Universitário
Lisboa Central, Lisboa, Portugal
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23
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Nesbit GM. Neurovascular disease and syndromes: Diagnosis and therapy in children. HANDBOOK OF CLINICAL NEUROLOGY 2020; 176:305-323. [PMID: 33272401 DOI: 10.1016/b978-0-444-64034-5.00015-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pediatric neurovascular disease runs the chronologic spectrum with dramatic changes in the presentation, evaluation, and treatment from the prenatal, perinatal, and infant periods through childhood and adolescence. These diseases are often dynamic throughout this period and the dynamic continues throughout life. There are four major categories: high-flow arteriovenous shunting lesions, arterial aneurysms, low-flow vascular lesions, and vascular occlusive disease. The high-flow lesions can be subdivided into a vein of Galen malformation, non-Galenic arteriovenous fistula, dural sinus malformations and fistula, and arteriovenous malformation. Low-flow vascular lesions include cerebral cavernous malformation, developmental venous anomaly, and capillary telangiectasia. The cerebrovascular occlusive disease can be divided between arterial occlusive disease and cerebral venous sinus thrombosis. The presentation of each of these entities can be very similar, especially in younger children; however, imaging and laboratory analysis can establish the diagnosis leading to the most appropriate therapy. A multidisciplinary team, dedicated to treating pediatric cerebrovascular disease, is important in delivering the best outcomes in these complex diseases. Given the relative rarity of pediatric presentation of cerebrovascular disease, many apply adult concepts to children. A better understanding of the diseases and their difference from adults makes a critical difference in selecting the correct approach.
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Affiliation(s)
- Gary M Nesbit
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, United States.
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24
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Cavalcante LBCP, Freitas TC, Musolino NRC, Cescato VAS, Silva GO, Fragoso MCBV, Puglia P, Bronstein MD, Machado MC. High accuracy of bilateral and simultaneous petrosal sinus sampling with desmopressin for the differential diagnosis of pediatric ACTH-dependent Cushing's syndrome. Pituitary 2020; 23:507-514. [PMID: 32451985 DOI: 10.1007/s11102-020-01051-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To analyze the bilateral and simultaneous petrosal sinus sampling (BIPSS) in a subgroup of children and adolescents with ACTH-dependent Cushing's syndrome (ADCS) METHODS: Retrospective study in a tertiary reference center. From 1993 and 2017, 19 children and adolescents (PED) were submitted to the BIPSS, median age of 14 years (range 9-19 years), 53% were males, 18 had Cushing's disease (CD) and one had ectopic ACTH syndrome (EAS). All procedures were performed with 10 µg of intravenous desmopressin. RESULTS The catheter positioning was successful in all cases. The central ACTH gradient was met in 17/19 cases. At baseline, central gradient occurred in 16/19 (84%) with gradient values of 7.2 ± 6.0. After stimulation, there was an increase in the center-periphery gradient values (33.6 ± 44.3). In one case, central gradient was defined only after stimulation. Two cases presented without a central gradient; one case of CD with a false-negative and one EAS case. Lateralization occurred in all cases with a central gradient. Confirmation of the tumor location presumed by the procedure with the surgical description occurred in 60% of the cases. The BIPSS in this PED subgroup of ADCS presented a sensitivity of 94.4% and specificity of 100%. There were no complications of the procedure. CONCLUSION In a series of children and adolescents with ADCS, BIPSS was safe and highly accurate in defining the central to peripheral ACTH gradient using desmopressin as secretagogue. Nevertheless, there was a limited value of the ACTH-gradient between the petrosal sinuses for the tumor location.
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Affiliation(s)
| | - Thais Castanheira Freitas
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | | | | | | | - Paulo Puglia
- Neuroradiology Service, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
- Laboratory of Cellular and Molecular Endocrinology/LIM25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Laboratory of Cellular and Molecular Endocrinology/LIM25, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
- Endocrinology Service, AC Camargo Cancer Center, Sao Paulo, SP, Brazil.
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25
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Lee KE, Zehri A, Soldozy S, Syed H, Catapano JS, Maurer R, Albuquerque FC, Liu KC, Wolfe SQ, Brown S, Levitt MR, Fargen KM. Dural venous sinus stenting for treatment of pediatric idiopathic intracranial hypertension. J Neurointerv Surg 2020; 13:465-470. [PMID: 32732257 DOI: 10.1136/neurintsurg-2020-016183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Dural venous sinus stenting (VSS) is an effective treatment for idiopathic intracranial hypertension (IIH) in adult patients. There are no published series to date evaluating safety and efficacy of VSS in pediatric patients. OBJECTIVE To report on procedural device selection and technique as well as safety and efficacy of VSS for pediatric patients with medically refractory IIH due to underlying venous sinus stenosis. METHODS A multi-institutional retrospective case series identified patients with medically refractory IIH aged less than 18 years who underwent VSS. RESULTS 14 patients were identified at four participating centers. Patient ages ranged from 10 to 17 years, and 10 patients (71.4%) were female. Mean body mass index was 25.7 kg/m2 (range 15.8-34.6 kg/m2). Stenting was performed under general endotracheal anesthesia in all except two patients. The average trans-stenotic gradient during diagnostic venography was 10.6 mm Hg. Patients had stents placed in the superior sagittal sinus, transverse sinus, sigmoid sinus, occipital sinus, and a combination. Average follow-up was 1.7 years after stenting. Six patients out of 10 (60%) had reduced medication dosing, 12 of 14 patients (85.7%) had improvements in headaches, two patients (100%) with pre-stent tinnitus had resolution of symptoms, and four (80%) of five patients with papilledema had improvement on follow-up ophthalmological examinations. Two patients (14.3%) developed postprocedural groin hematomas, one patient (7.1%) developed a groin pseudoaneurysm, and one patient (7.1%) had postprocedural groin bleeding. No other procedural complications occurred. Four patients (28.6%) required further surgical treatment (cerebrospinal shunting and/or stenting) after their first stenting procedure. CONCLUSIONS This series suggests that VSS is feasible in a pediatric population with IIH and has a low complication rate and good clinical outcomes.
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Affiliation(s)
- Katriel E Lee
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Aqib Zehri
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Sauson Soldozy
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Hasan Syed
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert Maurer
- Penn State Health Neurosurgery, Hershey, Pennsylvania, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Sandra Brown
- Cabarrus Eye Center, Concord, North Carolina, USA
| | - Michael R Levitt
- Department of Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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26
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Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities. Rev Neurol (Paris) 2020; 176:20-29. [DOI: 10.1016/j.neurol.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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27
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Starke RM, Snelling B, Al-Mufti F, Gandhi CD, Lee SK, Dabus G, Fraser JF. Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2019; 12:733-741. [PMID: 31818970 DOI: 10.1136/neurintsurg-2019-015573] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.
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Affiliation(s)
- Robert M Starke
- Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Brian Snelling
- Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Seon-Kyu Lee
- Radiology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
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28
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Wilson JL, Amlie-Lefond C, Abruzzo T, Orbach DB, Rivkin MJ, deVeber GA, Pergami P. Survey of practice patterns and preparedness for endovascular therapy in acute pediatric stroke. Childs Nerv Syst 2019; 35:2371-2378. [PMID: 31482313 DOI: 10.1007/s00381-019-04358-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Endovascular therapy benefits selected adults with acute stroke while data are lacking for children. The purpose of this study was to assess physician practice and institutional preparedness for endovascular therapy in pediatric stroke. METHODS A link to an anonymous online survey was sent to members of the International Pediatric Stroke Study (IPSS) group about physician experience with endovascular therapy, likelihood of treatment for provided clinical vignettes, and institutional readiness for the delivery of endovascular therapy to children. RESULTS Thirty-one pediatric physicians with a mean of 11 years (SD 7.1) of experience responded. All but two would consider endovascular therapy in a child, and 20 (64.5%) had recommended endovascular therapy for a child in the preceding year. Most (n = 19, 67.9%) did not commit to an age minimum for endovascular therapy. Sixteen (57.1%) would consider treatment up to 24 h after symptom onset with 19 (67.9%) respondents reporting that their practice changed after the 2018 American Heart Association guidelines extended the time window for endovascular therapy in adults. Seventeen (60.7%) preferred imaging that included perfusion in children presenting beyond 6 h. Nineteen (70.4%) had institutional endovascular therapy criteria. Physicians in larger pediatric groups had more "likely to treat" responses on the clinical vignettes than physicians working in smaller groups (11.7 vs. 6.1, p < 0.05). CONCLUSION Pediatric stroke physicians are largely willing to consider endovascular therapy with most changing their practice according to adult guidelines, though experience and selection criteria varied. These findings may help to inform consensus guidelines and clinical trial development.
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Affiliation(s)
- Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University, 707 SW Gaines St, Portland, OR, 97239, USA.
| | - Catherine Amlie-Lefond
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Hospital, Mayo Clinic College of Medicine and University of Arizona, Tucson, AZ, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J Rivkin
- Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, Boston, MA, USA
| | | | - Paola Pergami
- Pediatric Neurology, MedStar Georgetown University Hospital and Department of Neurology, Children's National Medical Center, Washington, DC, USA
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29
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Amlie-Lefond C, Wainwright MS. Organizing for Acute Arterial Ischemic Stroke in Children. Stroke 2019; 50:3662-3668. [DOI: 10.1161/strokeaha.119.025497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Mark S. Wainwright
- Division of Neurology, Seattle Children’s Hospital, University of Washington
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30
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Bhatia K, Kortman H, Blair C, Parker G, Brunacci D, Ang T, Worthington J, Muthusami P, Shoirah H, Mocco J, Krings T. Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series. J Neurosurg Pediatr 2019; 24:558-571. [PMID: 31398697 DOI: 10.3171/2019.5.peds19126] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/24/2019] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Kartik Bhatia
- 1Department of Neuroradiology, Toronto Western Hospital
- Departments of2Interventional Neuroradiology and
| | - Hans Kortman
- 1Department of Neuroradiology, Toronto Western Hospital
| | - Christopher Blair
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | | | - Timothy Ang
- Departments of2Interventional Neuroradiology and
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - John Worthington
- 3Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Prakash Muthusami
- 4Department of Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hazem Shoirah
- 5Department of Neurosurgery, Icahn School of Medicine at Mount Sinai; and
| | - J Mocco
- 6Department of Neurosurgery, The Mount Sinai Health System, New York, New York
| | - Timo Krings
- 1Department of Neuroradiology, Toronto Western Hospital
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31
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Barry M, Hallam DK, Bernard TJ, Amlie-Lefond C. What is the Role of Mechanical Thrombectomy in Childhood Stroke? Pediatr Neurol 2019; 95:19-25. [PMID: 30795888 DOI: 10.1016/j.pediatrneurol.2019.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Like adults, most children have lifelong morbidity after stroke. Revascularization therapies such as intravenous tissue plasminogen activator and mechanical thrombectomy may be options to decrease this morbidity in selected children, although currently there are no evidence-based recommendations to guide treatment. The utility and safety of mechanical thrombectomy in childhood stroke is unknown because of the lack of safety trials, case-controlled trials, and comprehensive retrospective studies. As such, the current rationale for the use of mechanical thrombectomy in childhood is based on extrapolation from adult experience, as well as consensus at individual institutions with many centers deciding care on a case-by-case basis. Nevertheless, the increasing use of recanalization therapies in appropriately selected adults with acute arterial ischemic stroke has led to an increase in consideration and use in childhood, and there are enough case reports and series, as well as experience, to suggest that some children with large vessel occlusion will likely benefit. METHODS We reviewed current literature regarding mechanical thrombectomy in childhood. RESULTS There are differences between pediatric and adult stroke which may impact safety, efficacy, and individual decision-making, including patient size, pathophysiology of stroke, deficit, experience, and lack of data regarding natural history of stroke in children. CONCLUSIONS Hospitals planning to perform mechanical thrombectomy in children should establish local procedures and guidelines for considering thrombectomy. In our experience, care is best provided through multidisciplinary teams including a pediatric vascular neurologist, neurointerventionalist with pediatric experience, and pediatric neurocritical care.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado
| | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Timothy J Bernard
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado; Hemophilia and Thrombosis Center, University of Colorado, Denver, Colorado
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Lee S, Heit JJ, Albers GW, Wintermark M, Jiang B, Bernier E, Fischbein NJ, Mlynash M, Marks MP, Do HM, Dodd RL. Neuroimaging selection for thrombectomy in pediatric stroke: a single-center experience. J Neurointerv Surg 2019; 11:940-946. [DOI: 10.1136/neurintsurg-2019-014862] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 11/04/2022]
Abstract
BackgroundThe extended time window for endovascular therapy in adult stroke represents an opportunity for stroke treatment in children for whom diagnosis may be delayed. However, selection criteria for pediatric thrombectomy has not been defined.MethodsWe performed a retrospective cohort study of patients aged <18 years presenting within 24 hours of acute large vessel occlusion. Patient consent was waived by our institutional IRB. Patient data derived from our institutional stroke database was compared between patients with good and poor outcome using Fisher’s exact test, t-test, or Mann-Whitney U-test.ResultsTwelve children were included: 8/12 (66.7%) were female, mean age 9.7±5.0 years, median National Institutes of Health Stroke Scale (NIHSS) 11.5 (IQR 10–14). Stroke etiology was cardioembolic in 75%, dissection in 16.7%, and cryptogenic in 8.3%. For 2/5 with perfusion imaging, Tmax >4 s appeared to better correlate with NIHSS. Nine patients (75%) were treated: seven underwent thrombectomy alone; one received IV alteplase and thrombectomy, and one received IV alteplase alone. Favorable outcome was achieved in 78% of treated patients versus 0% of untreated patients (P=0.018). All untreated patients had poor outcome, with death (n=2) or severe disability (n=1) at follow-up. Among treated patients, older children (12.8±2.9 vs 4.2±5.0 years, P=0.014) and children presenting as outpatient (100% vs 0%, P=0.028) appeared to have better outcomes.ConclusionsPerfusion imaging is feasible in pediatric stroke and may help identify salvageable tissue in extended time windows, though penumbral thresholds may differ from adult values. Further studies are needed to define criteria for thrombectomy in this unique population.
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33
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Endovascular mechanical thrombectomy for acute stroke in young children. J Neurointerv Surg 2019; 11:554-558. [DOI: 10.1136/neurintsurg-2018-014540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 11/03/2022]
Abstract
BackgroundMechanical thrombectomy has emerged as a standard of care for acute stroke from large vessel occlusion in adults but remains controversial in children. Cerebral vessels are nearly adult size by 5 years of age but the technical feasibility of achieving recanalization in younger and smaller children with current endovascular tools remains unclear.ObjectiveTo systematically review the literature on mechanical thrombectomy for stroke in children less than 5 years of age.ResultsMechanical thrombectomy for acute stroke has been reported in 11 children under the age of 5 years (range 9 months to 4 years). The mean time from symptom onset to groin puncture was 12 hours (range 4–50 hours). Complete recanalization was achieved in 7/12 (58%) vessels attempted, and partial recanalization in 4/12 (33%). Two procedure related complications were reported, with small vessel size felt to be contributory to basilar vasospasm in one case. Favorable neurological outcomes were reported in 7 cases (64%).ConclusionsOur review of the literature demonstrates that mechanical thrombectomy for acute ischemic stroke may be feasible in carefully selected infants and young children less than 5 years of age using currently available devices. Efficacy in promoting better neurologic outcomes remains unproven, and other questions persist, including whether complications such as vasospasm occur more frequently in young children compared with adults. Further study is needed to determine the safety and efficacy of pediatric mechanical thrombectomy. These data suggest that young children should not be excluded from future studies or clinical treatment on the basis of age alone.
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34
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Miao TL, Figueroa EL, Bajunaid K, Mayich M, de Ribaupierre S, Pandey SK. Use of a radial artery 'slender' sheath for facilitating transfemoral arterial access for neuroendovascular embolization in a very young infant. Interv Neuroradiol 2018; 25:353-356. [PMID: 30463500 DOI: 10.1177/1591019918813212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pediatric neuroendovascular procedures are increasingly performed as several studies have shown the safety of these interventions. In the literature, an upper limit of 4 French catheter size is conventionally used for femoral access in neuroangiography of very young infants. However, this constraint in luminal size may not allow for more complex procedures. We present the previously unreported use of a radial 5 French slender catheter with ultrathin walls for femoral access for aneurysm embolization in a 3-month-old boy presenting with left M2 aneurysm rupture.
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Affiliation(s)
- Timothy L Miao
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Enriqueta Lucar Figueroa
- 2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Khalid Bajunaid
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,3 Division of Neurosurgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Michael Mayich
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Sandrine de Ribaupierre
- 2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Sachin K Pandey
- 1 Department of Medical Imaging, University Hospital, London Health Sciences Centre, London, Ontario, Canada.,2 Clinical Neurological Sciences, Division of Neurosurgery, University Hospital, London Health Sciences Centre, London, Ontario, Canada
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Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol 2018; 3:245-252. [PMID: 30637131 PMCID: PMC6312071 DOI: 10.1136/svn-2018-000181] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach. Case descriptions We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome. Discussion Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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Davison MA, Ouyang B, Keppetipola KM, Chen M. Arterial diameter and the gender disparity in stroke thrombectomy outcomes. J Neurointerv Surg 2018; 10:949-952. [PMID: 29440356 DOI: 10.1136/neurintsurg-2017-013697] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Compared with males, females consistently fare worse following mechanical thrombectomy for large vessel ischemic strokes. Understanding why this gender disparity occurs may guide improvements in future treatment strategies. In this study, we aim to determine whether gender differences in cerebral arterial diameter correlate with clinical outcomes following stroke thrombectomy. METHODS We performed an observational study of consecutive acute ischemic stroke patients undergoing mechanical thrombectomy at a single, urban tertiary care medical center. Catheter angiographic images were used to manually measure proximal segment arterial diameters in a standardized fashion. Medical record review was used to obtain relevant independent and dependent variables. RESULTS Ninety two patients (42 females) between June 2013 and August 2016 met inclusion criteria. Internal carotid artery (ICA) terminus diameters for males and females were 3.08 mm (SD=0.46) and 2.81 mm (SD=0.45), respectively (P=0.01). M1 segment middle cerebral artery (MCA) diameters for males and females were 2.47 mm (SD=0.30) and 2.18 mm (SD=0.31), respectively (P<0.0001). 48% of patients in the upper MCA caliber tertile attained a favorable mRS 90 day value compared with 35% in each of the lower and middle tertiles (P=0.51). Larger MCA diameters correlated with favorable discharge disposition (P=0.21). CONCLUSIONS These results provide limited evidence that males have larger cerebral arterial diameters than females and that larger arterial diameters may improve the odds for favorable clinical outcomes. If future studies validate these findings, arterial diameter may become a relevant variable in the design of improved thrombectomy strategies.
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Affiliation(s)
- Mark A Davison
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bichun Ouyang
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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Bhogal P, Pérez MA, Wendl C, Bäzner H, Ganslandt O, Henkes H. Paediatric aneurysms – Review of endovascular treatment strategies. J Clin Neurosci 2017; 45:54-59. [DOI: 10.1016/j.jocn.2017.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
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Barburoglu M, Arat A. Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases. AJNR Am J Neuroradiol 2016; 38:113-118. [PMID: 27765738 DOI: 10.3174/ajnr.a4959] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children. MATERIALS AND METHODS Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children). RESULTS VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up. CONCLUSIONS Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.
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Affiliation(s)
- M Barburoglu
- From the Department of Radiology (M.B.), Istanbul University Medical School, Istanbul, Turkey
| | - A Arat
- Department of Radiology (A.A.), School of Medicine, Hacettepe University, Ankara, Turkey.
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Lena J, Eskandari R, Infinger L, Fargen KM, Spiotta A, Turk A, Turner RD, Chaudry I. Republished: Basilar artery occlusion in a child treated successfully with mechanical thrombectomy using ADAPT. J Neurointerv Surg 2016; 9:e2. [DOI: 10.1136/neurintsurg-2015-012195.rep] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 11/04/2022]
Abstract
Acute ischemic stroke (AIS) in the pediatric population is rare. Furthermore, it is common for physicians to take significantly longer diagnosing a posterior circulation stroke in a child than in an adult. There are increasing case reports in the literature of treating AIS in children with intravenous tissue plasminogen activator, intra-arterial thrombolysis, and/or mechanical thrombectomy. We present the first case of pediatric AIS treated using a direct aspiration first pass technique (ADAPT) as a means of mechanical thrombectomy.
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Lena J, Eskandari R, Infinger L, Fargen KM, Spiotta A, Turk A, Turner RD, Chaudry I. Basilar artery occlusion in a child treated successfully with mechanical thrombectomy using ADAPT. BMJ Case Rep 2016; 2016:bcr-2015-012195. [PMID: 27068722 DOI: 10.1136/bcr-2015-012195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute ischemic stroke (AIS) in the pediatric population is rare. Furthermore, it is common for physicians to take significantly longer diagnosing a posterior circulation stroke in a child than in an adult. There are increasing case reports in the literature of treating AIS in children with intravenous tissue plasminogen activator, intra-arterial thrombolysis, and/or mechanical thrombectomy. We present the first case of pediatric AIS treated using a direct aspiration first pass technique (ADAPT) as a means of mechanical thrombectomy.
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Affiliation(s)
- Jonathan Lena
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ramin Eskandari
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Libby Infinger
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro Spiotta
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aquilla Turk
- Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond D Turner
- Department of Neurosciences, Medical University of South Carolina, Mount Pleasant, South Carolina, USA
| | - Imran Chaudry
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
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