According to a study published in Neurology, thrombectomy was shown to be safe in children with ischemic stroke and a mismatch between clinical deficit and infarct size for up to 24 hours after symptoms appeared. The results indicated that the method generally gave good neurological results when patients were also selected by this mismatch.
Recent data suggest that mechanical thrombectomy may be a viable treatment option for pediatric patients with arterial ischemic stroke (AIS). The study researchers attempted to assess whether thrombectomy was safe for up to 24 hours after symptoms appeared in this population when selected by infarct-clinical deficit mismatch.
Of the 73 pediatric patients from the Save ChildS study, the researchers only included 20 children because of a relevant mismatch between clinical deficit and infarction. Patients had undergone thrombectomy 6 to 24 hours after initiation and were diagnosed with AIS. Study researchers compared patients treated later than 6 hours with patients treated within 6 hours of initiation and compared them to the clinical endpoints of the DAWN and DEFUSE 3 studies.
Patients treated in the late time window had favorable imaging constellations that were defined by a very limited infarct volume and / or a mismatch between clinical symptoms and infarct imaging. The median National Pediatric Institutes of Health Stroke Scale (PedNIHSS) at admission was 12 (IQR, 8.8-20.3). The study researchers found that the median time of thrombectomy from initiation was 9.8 hours (IQR, 7.8-16.2) and the median volume of infarct lesion on the recording imaging was 13.5 ml (IQR, 3.8 -25.2).
At discharge, the patients had a median modified Rankin Scale (mRS) of 1.0 (IQR, 1.0-1.6) with an improvement to 1.0 (IQR, 0-1.6) after 3 months 1.0 (IQR 0-1.0) after 6 months and after 24 months to 0.0 (IQR, 0-1.0). The collected data resulted in a mean PSOM (Pediatric Stroke Outcome Measure) value of 1.0 (IQR, 0.5-1.0) at discharge, 0.5 (IQR, 0.2-1.0) after 3 months , 0.5 (IQR, 0-1.0) after 6 months and 0.3 (IQR, 0-1.0) at 24 months after the intervention. The study researchers compared the mRS values at discharge and 90 days with those at 90 days in the DAWN and DEFUSE 3 studies. They reported less poor results in the population of their study. When assessing the mRS after 180 days, the results showed good results (mRS, 0-2) in children who were treated less than 6 hours after the onset of symptoms (91%) and for more than 6 hours after the onset of the symptoms (90%) .
In addition, most patients showed improvement in neurological deficit after thrombectomy. The study researchers recorded a mean PedNIHSS score of 12.0 (IQR, 8.8-20.3) at admission. This improved 12 to 24 months after thrombectomy to a median of 5.0 (IQR, 2.0-9.8) and on day 7 to 2.0 (IQR, 1.2-6.8).
Of the 20 patients, the angiographic results were good (≥ eTICI 2b) in 17 (85%) and poor (≤ eTICI 2a) in 3 (15%) patients.
The limitations of this study included the retrospective design, the lack of a control cohort, the use of the mRS in children with outcome assessment, and an unknown optimal definition of the selection criteria for a mismatch between clinical deficit and infarction.
The study researchers concluded that “thrombectomy for ischemic stroke in children appears safe for a longer window of time, up to 24 hours after symptoms appear, and neurological outcomes improve in most children.”
Sporns PB, Psychogios MN, Straeter R. et al. Clinical diffusion mismatch in selecting pediatric patients for embolectomy 6 to 24 hours after stroke. An analysis of the Save ChildS study. Neurology. Published online on November 3, 2020. doi: 10.1212 / WNL.0000000000011107