Abstract
Background
Acute intracranial large vessel occlusion (LVO) is an important cause of morbidity and mortality among children; however, unlike in adults, no clinical trial has investigated the benefit of mechanical thrombectomy (MT) in pediatric LVO. Thus, MT remains an off-label procedure for pediatric stroke.
Purpose
To investigate the efficacy and safety of MT in pediatric LVO.
Methods
A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies reporting safety and efficacy outcomes for endovascular treatment of pediatric LVO were included. Data regarding recanalization, functional outcome, symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. Functional outcome was assessed with the modified Rankin scale (mRS). A fixed or random-effects model was used to calculate pooled event rates and 95% confidence intervals (CI).
Results
In this study 11 studies comprising 215 patients were included. The successful recanalization rate was 90.3% (95% CI = 85.77–95.11%), and complete recanalization was achieved in 52.7% (95% CI = 45.09–61.62%) of the cases. The favorable (mRS = 0–2) and excellent (mRS = 0–1) outcome rates were 83.3% (95% CI = 73.54–94.50%) and 59.5% (95% CI = 44.24–80.06%), respectively. The overall sICH prevalence was 0.59% (95% CI = 0–3.30%) and mortality rate was 3.2% (95% CI = 0.55–7.38%).
Conclusion
In our meta-analysis, MT demonstrated a promising safety and efficacy profile for pediatric patients, with consistently high efficacy outcomes and low complication rates. Our results support the utilization of MT in pediatric LVOs; however, prospective studies are still needed to further establish the role of pediatric MT as a first-line treatment strategy.
Similar content being viewed by others
References
Mallick AA, Ganesan V, Kirkham FJ, Fallon P, Hedderly T, McShane T, Parker AP, Wassmer E, Wraige E, Amin S, Edwards HB, Tilling K, O’Callaghan FJ. Childhood arterial ischaemic stroke incidence, presenting features, and risk factors: a prospective population-based study. Lancet Neurol. 2014;13:35–43. https://doi.org/10.1016/s1474-4422(13)70290-4.
Sporns PB, Fullerton HJ, Lee S, Kirton A, Wildgruber M. Current treatment for childhood arterial ischaemic stroke. Lancet Child Adolesc Health. 2021;5:825–36. https://doi.org/10.1016/s2352-4642(21)00167-x.
de Veber GA, MacGregor D, Curtis R, Mayank S. Neurologic outcome in survivors of childhood arterial ischemic stroke and sinovenous thrombosis. J Child Neurol. 2000;15:316–24. https://doi.org/10.1177/088307380001500508.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. https://doi.org/10.1056/NEJMoa1411587.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30. https://doi.org/10.1056/NEJMoa1414905.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306. https://doi.org/10.1056/NEJMoa1503780.
Wintermark M, Hills NK, deVeber GA, Barkovich AJ, Elkind MS, Sear K, Zhu G, Leiva-Salinas C, Hou Q, Dowling MM, Bernard TJ, Friedman NR, Ichord RN, Fullerton HJ. Arteriopathy diagnosis in childhood arterial ischemic stroke: results of the vascular effects of infection in pediatric stroke study. Stroke. 2014;45:3597–605. https://doi.org/10.1161/strokeaha.114.007404.
Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers. 2022;8:12. https://doi.org/10.1038/s41572-022-00337-x.
He L, Ladner TR, Pruthi S, Day MA, Desai AA, Jordan LC, Froehler MT. Rule of 5: angiographic diameters of cervicocerebral arteries in children and compatibility with adult neurointerventional devices. J Neurointerv Surg. 2016;8:1067–71. https://doi.org/10.1136/neurintsurg-2015-012034.
Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Gailloud P, Pearl MS. Endovascular therapy for acute stroke in children: age and size technical limitations. J Neurointerv Surg. 2021;13:794–8. https://doi.org/10.1136/neurintsurg-2021-017311.
Heit JJ, Muthusami P, Chandra RV, Hui F, Negrotto M, Lee S, Wasserman BA, Abruzzo TA. Reperfusion therapies for children with arterial Ischemic stroke. Top Magn Reson Imaging. 2021;30:231–43. https://doi.org/10.1097/rmr.0000000000000273. PubMed PMID: 34613946.
Lehman LL, Beslow LA, Steinlin M, Kossorotoff M, Mackay MT. What will improve pediatric acute stroke care? Stroke. 2019;50:249–56. https://doi.org/10.1161/strokeaha.118.022881.
Beslow LA, Lo WD. Key metrics are required to refine guidelines for pediatric mechanical thrombectomy. Stroke. 2021;52:1222–4. https://doi.org/10.1161/strokeaha.120.033561.
Barry M, Barry D, Kansagra AP, Hallam D, Abraham M, Amlie-Lefond C. Higher-quality data collection is critical to establish the safety and efficacy of pediatric mechanical thrombectomy. Stroke. 2021;52:1213–21. https://doi.org/10.1161/strokeaha.120.032009.
Lee S, Felling RJ. Moving toward a new horizon of pediatric stroke intervention. Stroke. 2021;52:789–91. https://doi.org/10.1161/strokeaha.120.033496.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021;10:89. https://doi.org/10.1186/s13643-021-01626-4.
Fragata I, Morais T, Silva R, Nunes AP, Loureiro P, Martins DJ, Pamplona J, Carvalho R, Baptista M, Reis J. Endovascular treatment of pediatric ischemic stroke: A single center experience and review of the literature. Interv Neuroradiol. 2021;27:16–24. https://doi.org/10.1177/1591019920958827.
Bhatti A, Huded V, Vyas D, Mushtaq M, Kekatpure M, Hiremath S, Sapare A, Aggarwal R. Mechanical thrombectomy using retrievable Stents in pediatric acute Ischemic stroke. Indian Pediatr. 2019;56:571–5.
Shoirah H, Shallwani H, Siddiqui AH, Levy EI, Kenmuir CL, Jovin TG, Levitt MR, Kim LJ, Griauzde J, Pandey AS, Gemmete JJ, Abruzzo T, Arthur AS, Elijovich L, Hoit D, Cheema A, Aghaebrahim A, Sauvageau E, Hanel R, Ringer AJ, Nascimento FA, Kan P, Mocco J. Endovascular thrombectomy in pediatric patients with large vessel occlusion. J Neurointerv Surg. 2019;11:729–32. https://doi.org/10.1136/neurintsurg-2018-014320.
Bigi S, Dulcey A, Gralla J, Bernasconi C, Melliger A, Datta AN, Arnold M, Kaesmacher J, Fluss J, Hackenberg A, Maier O, Weber J, Poloni C, Fischer U, Steinlin M. Feasibility, safety, and outcome of recanalization treatment in childhood stroke. Ann Neurol. 2018;83:1125–32. https://doi.org/10.1002/ana.25242.
Bhatia KD, Briest R, Goetti R, Webster R, Troedson C, Dale RC, Muthusami P, Miteff C, Miteff F, Worthington J, Tastula K, Ang T, Andrews I. Incidence and natural history of pediatric large vessel occlusion stroke: a population study. JAMA Neurol. 2022;79:488–97. https://doi.org/10.1001/jamaneurol.2022.0323.
Ravindra VM, Alexander M, Taussky P, Bollo RJ, Hassan AE, Scoville JP, Griauzde J, Awad AW, Jumaa M, Zaidi S, Lee JJ, Hafeez MU, Nascimento FA, LoPresti MA, Couldwell WT, Hetts SW, Lam SK, Kan P, Grandhi R. Endovascular thrombectomy for pediatric acute Ischemic stroke: a multi-institutional experience of technical and clinical outcomes. Neurosurgery. 2020;88:46–54. https://doi.org/10.1093/neuros/nyaa312.
Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar PM, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol. 2018;3:245–52. https://doi.org/10.1136/svn-2018-000181.
van Es A, Hunfeld MAW, van den Wijngaard I, Kraemer U, Engelen M, van Hasselt B, Fransen PSS, Dippel DWJ, Majoie C, van der Lugt A, Emmer BJ. Endovascular treatment for acute ischemic stroke in children: experience from the MR CLEAN registry. Stroke. 2021;52:781–8. https://doi.org/10.1161/strokeaha.120.030210.
Zhou B, Wang XC, Xiang JY, Zhang MZ, Li B, Jiang HB, Lu XD. Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke. J Neurosurg Pediatr. 2019;23:363–8. https://doi.org/10.3171/2018.9.Peds18242.
Sporns PB, Sträter R, Minnerup J, Wiendl H, Hanning U, Chapot R, Henkes H, Henkes E, Grams A, Dorn F, Nikoubashman O, Wiesmann M, Bier G, Weber A, Broocks G, Fiehler J, Brehm A, Psychogios M, Kaiser D, Yilmaz U, Morotti A, Marik W, Nolz R, Jensen-Kondering U, Schmitz B, Schob S, Beuing O, Götz F, Trenkler J, Turowski B, Möhlenbruch M, Wendl C, Schramm P, Musolino P, Lee S, Schlamann M, Radbruch A, Rübsamen N, Karch A, Heindel W, Wildgruber M, Kemmling A. Feasibility, safety, and outcome of endovascular recanalization in childhood stroke: the save childS study. JAMA Neurol. 2020;77:25–34. https://doi.org/10.1001/jamaneurol.2019.3403.
Kossorotoff M, Kerleroux B, Boulouis G, Husson B, Dong TK, Eugene F, Damaj L, Ozanne A, Bellesme C, Rolland A, Bourcier R, Triquenot-Bagan A, Marnat G, Neau JP, Joriot S, Perez A, Guillen M, Perivier M, Audic F, Hak JF, Denier C, Naggara O. Recanalization treatments for pediatric acute Ischemic stroke in France. JAMA Netw Open. 2022;5:e2231343. https://doi.org/10.1001/jamanetworkopen.2022.31343.
Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, Hanft S, Bowers C, Yaghi S, Mayer SA, Al-Mufti F. Endovascular thrombectomy for pediatric acute ischemic stroke. Stroke. 2022;53:1530–9. https://doi.org/10.1161/strokeaha.121.036361.
Pienaar R, Paldino MJ, Madan N, Krishnamoorthy KS, Alsop DC, Dehaes M, Grant PE. A quantitative method for correlating observations of decreased apparent diffusion coefficient with elevated cerebral blood perfusion in newborns presenting cerebral ischemic insults. Neuroimage. 2012;63:1510–8. https://doi.org/10.1016/j.neuroimage.2012.07.062.
Chen J, Licht DJ, Smith SE, Agner SC, Mason S, Wang S, Silvestre DW, Detre JA, Zimmerman RA, Ichord RN, Wang J. Arterial spin labeling perfusion MRI in pediatric arterial ischemic stroke: initial experiences. J Magn Reson Imaging. 2009;29:282–90. https://doi.org/10.1002/jmri.21641.
Wright JN. Spontaneous recanalization and hyperperfusion are relatively common at presentation in pediatric arterial ischemic stroke. Neuroradiology. 2019;61:629–32. https://doi.org/10.1007/s00234-019-02213-0.
Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical thrombectomy for acute Ischemic stroke: considerations in children. Stroke. 2020;51:3174–81. https://doi.org/10.1161/strokeaha.120.029698.
Sporns PB, Straeter R, Minnerup J, Wiendl H, Hanning U, Chapot R, Henkes H, Henkes E, Grams A, Dorn F, Nikoubashman O, Wiesmann M, Bier G, Weber A, Broocks G, Fiehler J, Brehm A, Psychogios M, Kaiser D, Yilmaz U, Morotti A, Marik W, Nolz R, Jensen-Kondering U, Schmitz B, Schob S, Beuing O, Goetz F, Trenkler J, Turowski B, Möhlenbruch M, Wendl C, Schramm P, Musolino P, Lee S, Schlamann M, Radbruch A, Rübsamen N, Karch A, Heindel W, Wildgruber M, Kemmling A. Does device selection impact recanalization rate and neurological outcome?: an analysis of the save childS study. Stroke. 2020;51:1182–9. https://doi.org/10.1161/strokeaha.119.028221.
Sporns PB, Psychogios MN, Straeter R, Hanning U, Minnerup J, Chapot R, Henkes H, Henkes E, Grams A, Dorn F, Nikoubashman O, Wiesmann M, Bier G, Weber A, Broocks G, Fiehler J, Brehm A, Kaiser D, Yilmaz U, Morotti A, Marik W, Nolz R, Jensen-Kondering U, Braun M, Schob S, Beuing O, Goetz F, Trenkler J, Turowski B, Möhlenbruch M, Wendl C, Schramm P, Musolino PL, Lee S, Schlamann M, Radbruch A, Karch A, Rübsamen N, Wildgruber M, Kemmling A. Clinical diffusion mismatch to select pediatric patients for embolectomy 6 to 24 hours after stroke: an analysis of the save childS study. Neurology. 2021;96:e343–51. https://doi.org/10.1212/wnl.0000000000011107.
Chabrier S, Ozanne A, Naggara O, Boulouis G, Husson B, Kossorotoff M. Hyperacute recanalization strategies and childhood stroke in the evidence age. Stroke. 2021;52:381–4. https://doi.org/10.1161/strokeaha.120.031133.
Al-Mufti F, Schirmer CM, Starke RM, Chaudhary N, De Leacy R, Tjoumakaris SI, Haranhalli N, Abecassis IJ, Amuluru K, Bulsara KR, Hetts SW; SNIS Standards and Guidelines Committee and SNIS Board of Directors. Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg. 2022;14:1033–41. https://doi.org/10.1136/neurintsurg-2021-017888.
Sporns PB, Kemmling A, Lee S, Fullerton H, Kunz WG, Wilson JL, Mackay MT, Steinlin M, Fiehler J, Psychogios M, Wildgruber M. A prospective multicenter registry on feasibility, safety, and outcome of endovascular recanalization in childhood stroke (save childS pro). Front Neurol. 2021;12:736092. https://doi.org/10.3389/fneur.2021.736092.
Acknowledgements
We would like to thank the Save ChildS and KidClot investigators for sharing their unpublished data.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
J. Fiehler received research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, and Stryker; served as a consultant for Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, and Transverse Medical; has ownership interests in Tegus. D. F. Kallmes received research support from Cerenovus, Insera Therapeutics, Medtronic, Microvention, Balt, Monarch Biosciences, Brainomix, MiVi, and Stryker; received royalties from Medtronic; serves in advisory boards of NoNo Inc. and Vesalio; has ownership interests in Nested Knowledge, Superior Medical Experts, Marblehead Medical, Conway Medical, Monarch Biosciences, and Piraeus Medical. C. Bilgin, M. Ibrahim, A.Y. Azzam, S. Ghozy, A. Elswedy, H. Kobeissi, M. Sobhi Jabal, R. Kadirvel, G. Boulouis, O. Naggara, M. Psychogios, S. Lee, M. Wildgruber, A. Kemmling, F. Al-Mufti, M. Kossorotoff and P.B. Sporns declare that they have no competing interests.
Additional information
The authors Fawaz Al-Mufti, Manoelle Kossorotoff, Peter B. Sporns and David F. Kallmes contributed equally to the manuscript.
Supplementary Information
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Bilgin, C., Ibrahim, M., Azzam, A.Y. et al. Mechanical Thrombectomy for Pediatric Large Vessel Occlusions. Clin Neuroradiol 33, 635–644 (2023). https://doi.org/10.1007/s00062-022-01246-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00062-022-01246-y