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Published on: July 21, 2013
Cerebrovascular Collateral Integrity in Pediatric Large Vessel Occlusion: Analysis of the Save ChildS Study
Sarah Lee1, Bin Jiang2, Max Wintermark2
1From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland. slee10@stanford.edu.
Insights
In children with ischemic stroke, favorable cerebrovascular collaterals were linked to reduced stroke volume and slower infarct growth. However, these collaterals did not improve clinical outcomes in this study.
Area of Science:
- Neurology
- Pediatric Stroke
- Cerebrovascular Disease
Background:
- Cerebrovascular collaterals are crucial in adult stroke, influencing treatment and outcomes.
- The role of collaterals in pediatric ischemic stroke remains largely unknown.
- This study investigates the impact of collaterals in children undergoing thrombectomy.
Purpose of the Study:
- To determine if favorable collaterals correlate with better radiographic and clinical outcomes in pediatric ischemic stroke.
- To assess the relationship between collateral status and stroke volume, infarct growth, and clinical scores.
Main Methods:
- Retrospective analysis of 33 pediatric patients from the SaveChildS cohort (2000-2018).
- Collateral status graded using the Tan collateral score on acute neuroimaging.
- Correlation of collateral status with radiographic (stroke volume, ASPECTS) and clinical outcomes (modified Rankin Scale).
Main Results:
- Favorable collaterals were observed in 42.4% of patients.
- Patients with favorable collaterals had significantly smaller final stroke volumes (p=0.049).
- Favorable collaterals were associated with higher baseline ASPECTS (p=0.006) and slower early infarct growth rates (p=0.028), but not improved clinical outcomes.
Conclusions:
- Favorable collaterals in pediatric ischemic stroke are associated with better radiographic outcomes, including smaller stroke burden and slower infarct progression.
- Collateral status did not correlate with improved clinical outcomes in this cohort.
- Further prospective studies are required to fully elucidate the impact of collaterals in childhood stroke.
Background And Objectives:
Robust cerebrovascular collaterals in adult patients with large vessel occlusion stroke have been associated with longer treatment windows, better recanalization rates, and improved outcomes, but the role of collaterals in pediatric stroke is not known. The primary aim was to determine whether favorable collaterals correlated with better radiographic and clinical outcomes in children with ischemic stroke who underwent thrombectomy.
Methods:
This study analyzed a subset of children enrolled in SaveChildS, a retrospective, multicenter, observational cohort study of 73 pediatric patients with stroke who underwent thrombectomy between 2000 and 2018 at 27 US and European centers. Included patients had baseline angiographic imaging and follow-up modified Rankin Scale scores available for review. Posterior circulation occlusions were excluded. Cerebrovascular collaterals were graded on acute neuroimaging by 2 blinded neuroradiologists according to the Tan collateral score, in which favorable collaterals are defined as >50% filling and unfavorable collaterals as <50% filling distal to the occluded vessel. Collateral status was correlated with clinical and neuroimaging characteristics and outcomes. Between-group comparisons were performed with the Wilcoxon rank-sum test for continuous variables or Fisher exact test for binary variables.
Results:
Thirty-three children (mean age 10.9 [SD ±4.9]) years were included; 14 (42.4%) had favorable collaterals. Median final stroke volume as a percent of total brain volume (TBV) was significantly lower in patients with favorable collaterals (1.35% [interquartile range (IQR) 1.14%-3.76%] vs 7.86% [IQR 1.54%-11.07%], p = 0.049). Collateral status did not correlate with clinical outcome, infarct growth, or final Alberta Stroke Program Early CT Score (ASPECTS) in our cohort. Patients with favorable collaterals had higher baseline ASPECTS (7 [IQR 6-8] vs 5.5 [4-6], p = 0.006), smaller baseline ischemic volume (1.57% TBV [IQR 1.09%-2.29%] vs 3.42% TBV [IQR 1.26%-5.33%], p = 0.035), and slower early infarct growth rate (2.4 mL/h [IQR 1.5-5.1 mL/h] vs 10.4 mL/h [IQR 3.0-30.7 mL/h], p = 0.028).
Discussion:
Favorable collaterals were associated with smaller final stroke burden and slower early infarct growth rate but not with better clinical outcome in our study. Prospective studies are needed to determine the impact of collaterals in childhood stroke.
Classification Of Evidence:
This study provides Class II evidence that in children with ischemic stroke undergoing thrombectomy, favorable collaterals were associated with improved radiographic outcomes but not with better clinical outcomes.
