Mechanical thrombectomy is safe in childhood stroke and was found to have a similar safety profile to that reported in adult trials, according to study results published in JAMA Neurology.

While several randomized clinical trials have supported the efficacy and safety of endovascular recanalization for adults with large intracranial vessel occlusion, limited data are available on the outcomes of this intervention for childhood stroke. The goal of the current study was to investigate the safety profile and clinical outcomes of this therapy in children with ischemic stroke.

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In the retrospective, multicenter cohort study, the researchers analyzed data from radiologic databases from 27 European and US stroke centers. They focused on children (aged <18 years) diagnosed with arterial ischemic stroke who underwent endovascular recanalization between January 1, 2000, and December 31, 2018.

The primary outcome was the decrease of Pediatric National Institute of Health Stroke Scale (PedNIHSS) score from admission to day 7. Secondary outcomes were the modified Rankin scale results at 6 and 24 months, as well as complications rate.


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The cohort study included 73 children (51% boys, median age 11.3 years, median PedNIHSS score on admission, 14.0). Median time from onset to admission and to recanalization was 3 and 4 hours, respectively. Of these, 63 patients (86%) were diagnosed with anterior circulation vessel occlusion, and 10 (14%) had posterior circulation vessel occlusion. Intravenous thrombolysis was administered to 16 patients (22%) prior to endovascular treatment.

In most patients there was evidence for an improvement of neurologic deficit following thrombectomy, as median PedNIHSS score improved from a score of 14.0 on admission to a median score of 5.0 at 12 to 24 hours following the treatment and 4.0 at day 7.

Furthermore, the medical modified Rankin scale score was 1.0 at discharge (interquartile range [IQR], 1.0-2.0), 1.0 (IQR, 0-1.6) after 6 months, and 1.0 (IQR, 0-1.0) at 24 months.

As for the safety of the intervention, transient vasospasm, detected angiographically, was reported in 4 patients (5%), and in all cases resolved after treatment with nimodipine and with no clinical sequelae. Cardiac arrest occurred following the intervention in 1 patient who had a preexisting heart anomaly. There were no reports of arterial dissection, periprocedural thrombosis, or puncture site complications.

Postinterventional complications included a single case (1%) of symptomatic intracerebral hemorrhage and malignant infarction in 3 patients (4%).

A comparison with the adult trials included in the HERMES meta-analysis showed that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults. The proportion of symptomatic intracerebral hemorrhage events in the HERMES trials was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40).

The researchers noted the study had several limitations, including the retrospective design, missing data with possible selection bias, lack of a control group, and absence of standardized protocols of inclusion for thrombectomy in the different centers.

“The findings of our study may add to the growing evidence that mechanical thrombectomy is safe in childhood stroke,” concluded the researchers. They also add that “this study may support clinicians’ practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.”

Reference

Sporns PB, Sträter R, Minnerup J, et al. Feasibility, safety, and outcome of endovascular recanalization in childhood stroke: the Save ChildS study [published online October 14, 2019]. JAMA Neurol. doi:10.1001/jamaneurol.2019.3403