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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Recanalization Treatments for Pediatric Acute Ischemic Stroke in France
Manoëlle Kossorotoff1,2, Basile Kerleroux3,4, Grégoire Boulouis1,3,5
1Assistance publique-Hôpitaux de Paris, French Center for Pediatric Stroke, France.
Insights
Revascularization strategies like intravenous thrombolysis (IVT) and endovascular treatment (EVT) appear safe for acute ischemic stroke (AIS) in children. Outcomes were similar between IVT and EVT, despite differences in initial stroke severity.
Area of Science:
- Pediatric Neurology
- Vascular Neurology
- Interventional Neuroradiology
Background:
- Limited evidence exists on the effectiveness of revascularization strategies for acute ischemic stroke (AIS) in children.
- Intravenous thrombolysis (IVT) and endovascular treatment (EVT) are potential AIS interventions in pediatric populations.
Purpose of the Study:
- To evaluate the safety and efficacy of IVT and/or EVT in children diagnosed with AIS.
- To report clinical outcomes associated with these revascularization strategies.
Main Methods:
- A multicenter, nationwide cohort study (KidClot) analyzed data from children (excluding neonates) with AIS who received recanalization treatment between 2015 and 2018.
- Clinical outcomes were assessed using the modified Rankin Scale (mRS) at 90 days and 1 year, alongside mortality, symptomatic intracerebral hemorrhage, Pediatric National Institutes of Health Stroke Scale (pedNIHSS), and ASPECTS scores.
Main Results:
- Of 68 children, 44 received IVT and 40 received EVT. Median admission pedNIHSS was 13, higher in the EVT group. Successful reperfusion (≥mTICI 2b) occurred in 80% of EVT cases.
- Three deaths (4.4%) occurred. Symptomatic intracerebral hemorrhage occurred in 1 patient (all in the EVT group).
- Median mRS was 2 at 90 days and 1 at 1 year, with no significant difference between IVT and EVT groups despite initial severity variations.
Conclusions:
- The findings suggest that IVT and/or EVT are safe revascularization strategies for pediatric AIS.
- These interventions demonstrate comparable functional outcomes at 90 days and 1 year, supporting their use in this population.
Importance:
There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS).
Objectives:
To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS.
Design, Setting, And Participants:
The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment between January 1, 2015, and May 31, 2018. Data analysis was performed from January 1, 2015, to May 31, 2019.
Exposure:
IVT and/or EVT.
Main Outcomes And Measures:
Primary outcome was day 90 favorable outcome (modified Rankin Scale [mRs] 0-2, with 0 indicating no symptoms and 6 indicating death). Secondary end points included 1-year favorable outcome (mRs, 0-2), mortality, and symptomatic intracerebral hemorrhage. Other measures included the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), with pedNIHSS 0 indicating no symptoms, 1 to 4 corresponding to a minor stroke, 5 to 15 corresponding to a mild stroke, greater than 15 to 20: severe stroke, and the adult Alberta Stroke Program Early CT Score (ASPECTS), which provides segmental assessment of the vascular territory, with 1 point deducted from the initial score of 10 for every region involved (from 10 [no lesion] to 0 [maximum lesions]).
Results:
Overall, 68 children were included in 30 centers (IVT [n = 44]; EVT [n = 40]; 44 boys [64.7%]; median [IQR] age, 11 [4-16] years; anterior circulation involvement, 57 [83.8%]). Median (IQR) pedNIHSS score at admission was 13 (7-19), higher in the EVT group at 16 (IQR, 10-20) vs 9 (6-17) in the IVT only group (P < .01). Median time from stroke onset to imaging was higher in the EVT group at 3 hours and 7 minutes (IQR, 2 hours and 3 minutes to 6 hours and 24 minutes) vs 2 hours and 39 minutes (IQR, 1 hour and 51 minutes to 4 hours and 13 minutes) (P = .04). Median admission ASPECTS score was 8 (IQR, 6-9). The main stroke etiologies were cardioembolic (21 [30.9%]) and focal cerebral arteriopathy (17 [25.0%]). Median (IQR) time from stroke onset to IVT was 3 hours and 30 minutes (IQR, 2 hours and 33 minutes to 4 hours and 28 minutes). In the EVT group, the rate of postprocedure successful reperfusion (≥modified Treatment in Cerebral Infarction 2b) was 80.0% (32 of 40). Persistent proximal arterial stenosis was more frequent in focal cerebral arteriopathy (P < .01). Death occurred in 3 patients (4.4%). Median pedNIHSS reduction at 24 hours was 4 (IQR, 0-9) points. Intracerebral hemorrhage occurred in 4 patients and symptomatic intracerebral hemorrhage occurred in 1 patient, all in the EVT group. The median mRS was 2 (IQR, 0-3) at day 90 and 1 (IQR, 0-2) at 1 year, which was not significantly different between EVT and IVT only groups, although different in initial severity.
Conclusions And Relevance:
The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.
