Thrombectomy for Pediatric Large Vessel Occlusion Stroke With Mild Presenting Symptoms

Neurologic outcomes after pediatric large vessel occlusion (LVO) stroke are poor. In the absence of a pediatric randomized clinical trial, cohort and registry studies have demonstrated improved outcomes with thrombectomy compared with medical management alone. However, the benefit of thrombectomy in children with LVO and mild presenting symptoms remains uncertain. Our objective was to determine if thrombectomy is associated with superior functional outcomes compared with medical management alone in pediatric patients with acute LVO stroke and mild presenting symptoms.

We undertook a case-control study pooling individual patient data from 4 published cohort studies on pediatric LVO stroke (Save ChildS, Save ChildS Pro, KidClot, Pediatric LVO Stroke Study), with patients treated at 75 centers across Europe, North America, and Australia between 2000 and 2023. Patients ≤18 years of age with acute LVO stroke on imaging and pediatric NIH Stroke Scale score ≤5 on admission were included. Patients treated with endovascular thrombectomy were compared with those treated with medical management alone. The primary clinical outcome was the functional status at 3 months after stroke, measured using the pediatric modified Rankin Scale and compared between groups using ordinal regression analysis. The primary safety outcome was the rate of symptomatic intracerebral hemorrhage.

Pooled data identified 63 pediatric patients (female: n = 21, 33.3%; mean age 9.6 years, SD 5.1, range 0.5-18.0) who met the inclusion criteria. The cohorts were well balanced for IV thrombolysis status, age, sex, site and side of occlusion, ASPECTS, and stroke etiology. Thrombectomy treated patients (n = 25) had significantly better pediatric modified Rankin Scale scores at 3 months than medically managed patients (n = 38; odds ratio 5.5 [95% CI 1.22-24.81]; p = 0.027). In the medical management group, n = 13 (34.2%) of patients had early neurologic deterioration in the first 24 hours, compared with only one patient in the thrombectomy group (4%, p = 0.005). No symptomatic intracerebral hemorrhages occurred in either group.

Thrombectomy in pediatric LVO stroke with mild presenting symptoms results in improved clinical outcomes compared with medical management alone and may prevent early neurologic deterioration. These findings can assist treating teams with acute clinical decision making in this complex clinical situation.

This study provides Class III evidence that in pediatric patients with acute LVO stroke and mild presenting symptoms, thrombectomy results in better functional outcomes compared with medical management alone.