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Hyperacute Perfusion Imaging Before Pediatric Thrombectomy: Analysis of the Save ChildS Study
Sarah Lee1, Michael Mlynash2, Soren Christensen2
1From the Department of Neurology and Neurological Sciences (S.L., M.M., S.C.), Stanford Stroke Center, Stanford University School of Medicine, CA; Division of Child Neurology (S.L.), Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA; Division of Neuroradiology (B.J.), Department of Radiology, Stanford University School of Medicine, CA; Department of Neuroradiology (M.W.), University of Texas MD Anderson, Houston, TX; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F.), University Medical Center Hamburg-Eppendorf, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (O.N.), RWTH Aachen University, Germany; Department of Neurological Sciences and Vision (A.M.), Neurology Unit, ASST Spedali Civili, Brescia, Italy; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M.M.), Heidelberg University Hospital; Department of Radiology (M.W.), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Switzerland. slee10@stanford.edu.
Insights
Perfusion imaging is feasible in pediatric stroke and does not delay thrombectomy. Favorable hypoperfusion intensity ratio (HIR) in children with large vessel occlusion stroke correlates with better functional outcomes.
Area of Science:
- Neurology
- Radiology
- Pediatric Medicine
Background:
- Perfusion imaging identifies salvageable brain tissue in adults for thrombectomy.
- The feasibility of hyperacute perfusion imaging in pediatric stroke is not well-established.
- Pediatric large vessel occlusion stroke requires evaluation of advanced imaging techniques.
Purpose of the Study:
- To determine if contrast perfusion imaging delays treatment time in pediatric stroke.
- To assess perfusion profiles in children with large vessel occlusion stroke.
- To evaluate the feasibility of acute perfusion imaging in pediatric stroke patients.
Main Methods:
- Retrospective analysis of the Save ChildS cohort (2000-2018) including children (1 month-18 years) with stroke undergoing thrombectomy.
- Secondary analysis focused on patients with anterior circulation occlusion and available neuroimaging for core laboratory review.
- Descriptive evaluation of perfusion imaging parameters due to small sample size.
Main Results:
- Perfusion imaging (CT or MR) was technically adequate in 15/33 (45.4%) pediatric stroke patients.
- Time from onset to recanalization did not differ significantly between groups with and without perfusion imaging (p=0.158).
- Favorable hypoperfusion intensity ratio (HIR) was observed in 11/15 patients and correlated with better 6-month functional outcomes (p=0.026 and p=0.048).
Conclusions:
- Automated perfusion imaging is feasible in acute pediatric stroke and does not delay time to recanalization.
- Larger prospective studies are necessary to identify biomarkers for favorable outcomes in pediatric ischemic stroke.
- Establishing core and penumbral thresholds for perfusion imaging in children is crucial.
Background And Objectives:
Perfusion imaging can identify adult patients with salvageable brain tissue who would benefit from thrombectomy in later time windows. The feasibility of obtaining hyperacute perfusion sequences in pediatric stroke is unknown. The aim of this study was to determine whether contrast perfusion imaging delayed time to treatment and to assess perfusion profiles in children with large vessel occlusion stroke.
Methods:
The Save ChildS retrospective cohort study (January 2000-December 2018) enrolled children (1 month-18 years) with stroke who underwent thrombectomy from 27 European and U.S. stroke centers. This secondary analysis included patients with anterior circulation occlusion and available imaging for direct review by the neuroimaging core laboratory. Between-group comparisons were performed using the Wilcoxon rank-sum exact test for continuous variables or Fisher exact test for binary variables. Given the small number of patients, evaluation of perfusion imaging parameters was performed descriptively only.
Results:
Of 33 patients with available neuroimaging, 15 (45.4%) underwent perfusion (CT perfusion n = 6; MR perfusion n = 9); all were technically adequate. The median time from onset to recanalization did not differ between groups {4 hours (interquartile range [IQR] 4-7.5) perfusion+; 3.4 hours (IQR 2.5-6.5) perfusion-, p = 0.158}. Target mismatch criteria were met by 10/15 (66.7%) patients and did not correlate with reperfusion status or functional outcome. The hypoperfusion intensity ratio (HIR) was favorable in 11/15 patients and correlated with older age but not NIHSS, time to recanalization, or stroke etiology. Favorable HIR was associated with better functional outcome at 6 months (Pediatric Stroke Outcome Measure 1.0 [IQR 0.5-2.0] vs 2.0 [1.5-3.0], p = 0.026) and modified Rankin Scale 1.0 [0-1] vs 2.0 [1.5-3.5], p = 0.048) in this small sample.
Discussion:
Automated perfusion imaging is feasible to obtain acutely in children and does not delay time to recanalization. Larger prospective studies are needed to determine biomarkers of favorable outcome in pediatric ischemic stroke and to establish core and penumbral thresholds in children.
