Thrombectomy may benefit children with stroke, large vessel occlusion
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Children with ischemic stroke with large vessel occlusion appear to benefit from mechanical thrombectomy, researchers reported at the International Stroke Conference.
“We know that, in adults, when they get an occlusion in one of the large arteries of the brain, they get very severe and disabling strokes, which we call large vessel occlusions (LVOs), and we know patients with stroke who have an LVO do much worse than patients without an LVO,” Kartik Bhatia, MBBS, BMedSci (Hons), MS, PhD, FRANZCR, CCINR, pediatric neurointerventionalist at the Sydney Children’s Hospital Network and director of Sydney Aneurysm, said at a press conference. “We have had at least seven positive randomized controlled trials since 2015 showing benefit of mechanical thrombectomy over standard treatment in adults with large vessel occlusion. However, none of the trials included children; that’s not surprising, as lots of randomized trials do not include children because of the ethical concerns and the consent issues. But one of the problems is that it’s hard to apply the results to children once they come back positive in adults. For some time now, there has been a hindrance in uptake of thrombectomy in children. We need that data so when I sit down with a parent before offering thrombectomy for their child, I can say I know what the outcome is likely to be.”
Because conducting a randomized trial of mechanical thrombectomy in children would be unethical and unfeasible, Bhatia and colleagues decided to test the hypothesis that children with untreated ischemic stroke with LVO have poor outcomes by conducting a retrospective multicenter cohort study comparing 127 children who had ischemic stroke without LVO (median age, 4 years; 33% girls), 26 children who had ischemic stroke with LVO but were not treated with thrombectomy, and 13 children who had ischemic stroke with LVO and were treated with thrombectomy (median age of combined LVO cohort, 8 years; 41% girls).
Among the children in the combined LVO cohort, 82% would have met the criteria for selection into the mechanical thrombectomy trials if they had been adults, Bhatia said at the press conference.
“The argument that children present too late and would not fulfill the criteria for thrombectomy is not supported by our data,” he said.
At 3 months, 73.1% of the LVO group that were not treated with thrombectomy had poor outcomes, defined as modified Rankin Scale score of 3 to 6, which was worse than the non-LVO group (OR = 3.64; P = .001), the LVO group treated with thrombectomy (OR = 3.75; P = .042) and the LVO group treated with thrombectomy for anterior circulation alone (OR = 7.14; P = .01). Bhatia said at the press conference.
At final assessment after a mean of 53 months follow-up, 57.7% of the LVO group that was not treated with thrombectomy had poor outcomes, a worse rate than the other groups (OR vs. non-LVO = 3.23; P = .003; OR vs. LVO with thrombectomy = 6.07; P = .01; OR vs. LVO with thrombectomy for anterior circulation alone = 8.6; P = .007), he said.
“Children with untreated large vessel occlusion have poor outcomes; three out of four have moderate to severe disability or die within 3 months,” Bhatia said at the press conference. “They have significantly worse outcomes than children who don’t have a large vessel occlusion. They have significantly worse outcomes than children who got a thrombectomy, and with adults who got a thrombectomy when you look at historic data. With such poor outcomes, we should definitely more strongly consider thrombectomy for children and update our guidelines now that we know exactly how badly they will do if we do nothing. We should triage and image children with large vessel occlusion earlier, because that seems to be the biggest problem — we are not getting them through our hospitals and to the thrombectomy suite in time.”
The study “answers one big question, albeit with a very small number of patients, but that’s probably going to be as good as it gets,” Tudor G. Jovin, MD, FAHA, chairman and chief of neurology at Cooper University Health Care in Camden, New Jersey, and medical director of Cooper Neurological Institute, said during a discussion at the press conference. “We see that in this population, the natural history is not that much different than in adults. That is a huge insight coming out of this study. We instinctively knew that they would do better with endovascular therapy, and the study ... tells us that kids with large vessel occlusions don’t do that well. We don’t have randomized data, but it’s going to be very difficult to generate it. There are already a lot of centers that treat pediatric stroke like adult stroke, and today’s study brings us closer to that being adopted widely in clinical practice.”
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Bhatia K, et al. LB22. Presented at: International Stroke Conference; Feb. 9-11, 2022; New Orleans (hybrid meeting).
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