Thrombectomy Improves Outcomes in Pediatric Stroke

Gwendolyn Rak

August 04, 2023

For children with stroke from large vessel occlusion, thrombectomy may result in better outcomes than medical management alone.

A matched case-control study followed 52 patients in Canada and Australia with acute stroke and assessed functional outcomes at 3 months for those who received thrombectomy, compared with those who did not. Patients receiving the procedure had significantly improved clinical outcomes (odds ratio [OR], 3.76). The procedure is the standard of care for adults with large vessel occlusion (LVO) stroke, but limited data exists for children.  

"In the absence of a randomized trial, this case-control study demonstrates better clinical outcomes with thrombectomy than medical management for pediatric patients aged 2 to 18 years with anterior circulation LVO stroke," the authors conclude in the study.

The study was published in JAMA Neurology on July 24.

Improved Results

Untreated LVO stroke is associated with poor outcomes, indicated in this study with scoring based on the modified Rankin Scale, a measure used to assess the degree of disability following the patient’s stroke. Based on this scoring, 53.8% of patients who were managed conservatively had poor outcomes (moderate disability or greater) at 3 months, confirming previous findings. The data was drawn from five hospitals in Australia and Canada between January 2011 and April 2022.

Removing blood clots with mechanical thrombectomy resulted in improved outcomes 3 months after stroke for the patients included in the study, compared with the neuroprotective measures of medical therapy alone. The improved outcomes persisted in the final available follow-up (OR, 3.65).

In adults, thrombectomy has previously been demonstrated to be a safe and effective treatment for LVO stroke and is currently the standard of care. This study sought to expand the data for pediatric patients, for whom stroke is rarer and difficult to diagnose.

The authors caution, however, that the outcomes are from hospitals with pediatric neurology expertise and should not be generalized to settings without specialists.

Case-Control Study

While previous population-based studies of children with LVO stroke found that conservative treatment was associated with poor outcomes, these studies may include significant selection bias. The investigators chose to conduct the case-control study as an alternative to a randomized control trial, which would require withholding treatment from some patients and would not be considered ethical.

The study included 26 patients in each cohort, either receiving mechanical thrombectomy or medical treatment alone. The investigators matched patients by site and side of occlusion, age, and sex. Cases that could not be matched by site of occlusion, the primary criterion, were excluded.

With this methodology, the investigators reduced the impact of selection bias with the aim of providing "the next highest level of comparative evidence," they state in the study. However, they also note that, without randomization, there is likely still some selection bias present.

The two cohorts were not significantly different based on factors such as sex or age. All patients in the study also presented within 24 hours of symptom onset, with most eligible for thrombectomy by adult standards. There was a difference between the two cohorts in the timing of arrival to a dedicated hospital and imaging. "Our triage, imaging, and decision-making pathways require streamlining," the authors conclude regarding the difference.

'A Heterogeneous Condition'

Commenting on the study for Medscape, Ratika Srivastava, MD, a pediatric neurologist at the University of Alberta, Edmonton, Alberta, Canada, said she was glad to see a well-designed study dedicated to pediatric stroke. Neurologists have traditionally extrapolated from research on adult stroke due to the rarity of pediatric stroke and difficulty of diagnosis.

Dr Ratika Srivastava

While physicians have previously relied on findings in adults, stroke presents differently in children. "The challenge is that it’s such a heterogeneous condition," said Srivastava, who was not involved in the study. In children, stroke may have several different etiologies, such as a lesion in the heart or arterial disease. "Sometimes it’s amenable to taking the clot out and sometimes it’s not. So you have to figure out: are they a good candidate for thrombectomy?" This study helps demonstrate that thrombectomy is a good option for some children with LVO stroke, she said.

The study was independently supported. Srivastava reports no relevant financial relationships.

JAMA Neurol. July 24, 2023. Abstract.

Gwendolyn Rak is a health reporter for Medscape and Univadis based in Brooklyn, New York.

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