Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

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OBJECTIVE

The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.

METHODS

Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).

RESULTS

The authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.

CONCLUSIONS

Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

ABBREVIATIONS AHA = American Heart Association; ASA = American Stroke Association; IA = intra-arterial; ICA = internal carotid artery; IPD = individual participant data; IV = intravenous; MCA = middle cerebral artery; mRS = modified Rankin Scale; MT = mechanical thrombectomy; mTICI = modified Thrombolysis in Cerebral Infarction; NIHSS = National Institutes of Health Stroke Scale; PSOM = Pediatric Stroke Outcome Measure; tPA = tissue plasminogen activator.

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Contributor Notes

Correspondence Kartik Bhatia: Toronto Western Hospital, Toronto, Ontario, Canada. kartik.bhatia@uhn.ca.INCLUDE WHEN CITING Published online August 9, 2019; DOI: 10.3171/2019.5.PEDS19126.Disclosures Dr. Worthington reports that he is director of the RPA Hospital Comprehensive Stroke Service and that reported cases include those from his own service. Dr. Mocco reports a consultant relationship with Imperative Care, Cerebrotech, Viseon, Endostream, Rebound Therapeutics, and Vastrax; ownership interest in Blink TBI, Serenity, NTI, Neurvana, and Cardinal Consulting; and receipt of research support from Stryker, Penumbra, Medtronic, and MicroVention.
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