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Original Investigation
October 14, 2019

Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study

Author Affiliations
  • 1Institute of Clinical Radiology, University Hospital of Muenster, Muenster, Germany
  • 2Department of Pediatrics, University Hospital of Muenster, Muenster, Germany
  • 3Department of Neurology, University Hospital of Muenster, Muenster, Germany
  • 4Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  • 5Department of Neuroradiology, Alfried-Krupp Hospital, Essen, Germany
  • 6Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
  • 7Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
  • 8Department for Diagnostic and Interventional Neuroradiology, University of Munich, Campus Grosshadern, Munich, Germany
  • 9Department of Neuroradiology, Aachen University, Aachen, Germany
  • 10Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Tuebingen, Germany
  • 11Department of Radiology and Neuroradiology, Bochum, Germany
  • 12Department of Diagnostic and Interventional Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
  • 13Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
  • 14Department of Neuroradiology, Saarland University Hospital, Homburg, Germany
  • 15Department of Neurology and Neurorehabilitation, Mondino Foundation, Pavia, Italy
  • 16Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
  • 17Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
  • 18Department of Radiology and Neuroradiology, University Hospital of Schleswig-Holstein, Kiel, Germany
  • 19Section of Neuroradiology, University of Ulm, Guenzburg, Germany
  • 20Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
  • 21Department of Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
  • 22Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
  • 23Department of Neuroradiology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
  • 24Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
  • 25Department of Neuroradiology at Heidelberg University Hospital, Heidelberg, Germany
  • 26Department of Radiology, University Hospital Regensburg, Regensburg, Germany
  • 27Department of Neuroradiology, University Hospital of Luebeck, Luebeck, Germany
  • 28Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
  • 29Division of Child Neurology, Department of Neurology, Stanford University, Stanford, California
  • 30Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany
  • 31Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
  • 32Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
JAMA Neurol. 2020;77(1):25-34. doi:10.1001/jamaneurol.2019.3403
Key Points

Question  Is endovascular treatment in pediatric patients (<18 years) associated with ischemic stroke and the clinical outcome?

Findings  In this cohort study including 73 children, endovascular recanalization appeared to be safe with positive outcomes in a real-world setting (proportion of successful recanalization, 87%). The study findings suggest that neurologic outcomes of the children were mostly favorable and comparable with those noted in adult trials.

Meaning  This study appears to support the level of evidence in favor of endovascular recanalization in children with acute, large-vessel occlusion; a higher strength of recommendation may contribute to clinical outcome in children affected by arterial ischemic stroke.

Abstract

Importance  Randomized clinical trials have shown the efficacy of thrombectomy of large intracranial vessel occlusions in adults; however, any association of therapy with clinical outcomes in children is unknown.

Objective  To evaluate the use of endovascular recanalization in pediatric patients with arterial ischemic stroke.

Design, Setting, and Participants  This retrospective, multicenter cohort study, conducted from January 1, 2000, to December 31, 2018, analyzed the databases from 27 stroke centers in Europe and the United States. Included were all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization. Median follow-up time was 16 months.

Exposures  Endovascular recanalization.

Main Outcomes and Measures  The decrease of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission to day 7 was the primary outcome (score range: 0 [no deficit] to 34 [maximum deficit]). Secondary clinical outcomes included the modified Rankin scale (mRS) (score range: 0 [no deficit] to 6 [death]) at 6 and 24 months and rate of complications.

Results  Seventy-three children from 27 participating stroke centers were included. Median age was 11.3 years (interquartile range [IQR], 7.0-15.0); 37 patients (51%) were boys, and 36 patients (49%) were girls. Sixty-three children (86%) received treatment for anterior circulation occlusion and 10 patients (14%) received treatment for posterior circulation occlusion; 16 patients (22%) received concomitant intravenous thrombolysis. Neurologic outcome improved from a median PedNIHSS score of 14.0 (IQR, 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7. Median mRS score was 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months. One patient (1%) developed a postinterventional bleeding complication and 4 patients (5%) developed transient peri-interventional vasospasm. The proportion of symptomatic intracerebral hemorrhage events in the HERMES meta-analysis of trials with adults was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40).

Conclusions and Relevance  The results of this study suggest that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults; most of the treated children had favorable neurologic outcomes. This study may support clinicians’ practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.

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