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Published on: December 15, 2023
Ischemic stroke following elective craniotomy in children
Nickalus R Khan1, Kenneth Moore1, Jaafar Basma1
1Departments of1Neurosurgery and.
Insights
Pediatric ischemic stroke after elective craniotomy is rare, occurring in 1.8% of cases, primarily following tumor resection. Perforator artery infarcts are most common but may be missed by intraoperative MRI (iMRI).
Area of Science:
- Pediatric Neurosurgery
- Cerebrovascular Neurology
- Medical Imaging
Background:
- Perioperative ischemic stroke following elective craniotomy in children is considered uncommon.
- Limited published data exists on the incidence and characteristics of pediatric post-craniotomy strokes.
- Understanding stroke occurrence is crucial for improving patient outcomes after pediatric intracranial surgery.
Purpose of the Study:
- To investigate the incidence of perioperative stroke after elective craniotomy in a pediatric hospital.
- To identify risk factors and characteristics of ischemic strokes occurring post-pediatric craniotomy.
- To evaluate the diagnostic utility of intraoperative MRI (iMRI) for detecting these strokes.
Main Methods:
- Retrospective review of pediatric patients undergoing elective craniotomy between 2010 and 2017.
- Data collection from an institutional database including demographics, medical history, radiological findings, and outcomes.
- Analysis of stroke occurrence, timing, location, etiology, and detection methods.
Main Results:
- A total of 1591 elective craniotomies were performed, with 28 (1.8%) followed by a perioperative stroke.
- Strokes predominantly occurred adjacent to tumor resection sites (86%), were unilateral (89%), unifocal (93%), and supratentorial (93%).
- Perforating artery infarcts were most common (39.3%), followed by large vessel (35.7%), venous (14.3%), and hypoperfusion/embolic causes (10.7%).
- Intraoperative MRI (iMRI) failed to detect 55% of deep infarcts.
Conclusions:
- The incidence of ischemic stroke after pediatric elective craniotomy is low (1.8%).
- Tumor resection is the primary context for these strokes, with perforator artery infarcts being the most frequent type.
- Deep infarcts may be missed by intraoperative MRI (iMRI), highlighting potential limitations in real-time detection.
Abstract:
OBJECTIVE An ischemic stroke following an elective craniotomy in a child is perceived to be a rare event. However, to date there are few papers on this topic. The purpose of this study was to investigate the occurrence of stroke following elective intracranial surgery at a children’s hospital. METHODS The authors performed a retrospective review of all patients who developed a perioperative stroke following an elective craniotomy from 2010 through 2017. Data were collected using an institutional database that contained demographic, medical, radiological, and outcome variables. RESULTS A total of 1591 elective craniotomies were performed at the authors’ institution during the study period. Of these, 28 (1.8%) were followed by a perioperative stroke. Radiographic diagnosis of the infarction occurred at a median of 1.7 days (range 0–9 days) from the time of surgery, and neurological deficits were apparent within 24 hours of surgery in 18 patients (62.5%). Infarcts tended to occur adjacent to tumor resection sites (86% of cases), and in a unilateral (89%), unifocal (93%), and supratentorial (93%) location. Overall, 11 (39.3%) strokes were due to a perforating artery, 10 (35.7%) were due to a large vessel, 4 (14.3%) were venous, and 3 (10.7%) were related to hypoperfusion or embolic causes. Intraoperative MRI (iMRI) was used in 11 of the 28 cases, and 6 (55%) infarcts were not detected, all of which were deep. CONCLUSIONS The incidence of stroke following an elective craniotomy is low, with nearly all cases (86%) occurring after tumor resection. Perforator infarcts were most common but may be missed on iMRI. ABBREVIATIONS ACA = anterior cerebral artery; AChA = anterior choroidal artery; ACS NSQIP-P = American College of Surgeons National Surgical Quality Improvement Program–Pediatric; CVA = cerebrovascular accident; DWI = diffusion weighted imaging; iMRI = intraoperative MRI; MCA = middle cerebral artery; mRS = modified Rankin Scale; PCA = posterior cerebral artery.
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