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Save ChildS With Large Vessel Occlusion Using Commonly Available Endovascular Devices?
Stroke ( IF 6.046 ) Pub Date : 2020-03-02 , DOI: 10.1161/strokeaha.120.029166
Aristeidis H Katsanos

See related article, p 1182 Endovascular thrombectomy (EVT) is the only treatment modality available to date that can improve functional outcomes and reduce mortality in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO).1 Despite the high level of evidence for the utility of EVT in the adult population, there is uncertainty whether the benefits of EVT also extend for patients <18 years of age, who were not enrolled in randomized-controlled clinical trials.1 The use of EVT in the pediatric population with AIS due to LVO has only been presented in scarce case reports and case-series, raising inevitably questions on the efficacy and predominantly on the safety of using the relatively large endovascular devices in children.2 The Save ChildS Study is the first retrospective, multicenter cohort study suggesting comparable safety data for EVT in children <18 years of age compared with those presented by randomized-controlled clinical trials performed in the adult population.3 In a secondary post hoc analysis, published in the current issue of Stroke, Save ChildS investigators searched for potential disparities on the angiographic and clinical outcomes following EVT by stratifying for the different EVT techniques and devices used.4 Authors uncovered no association of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters, concluding that EVT should be offered in eligible children presenting with AIS due to LVO regardless of technical preferences or device availability.4 The findings from the Save ChildS investigators3,4 definitely provide further reassurance to clinicians opting in for EVT in cases of children presenting with AIS due to an LVO. Some special features and considerations, not very frequently encountered in the adult AIS literature, though deserve to be highlighted. Despite the participation of 27 tertiary centers, only 73 children with AIS due to LVO treated with EVT were identified over a period of 18 years (January 2000 to December 2018).3,4 According to a US nationwide study, <1% of children with AIS finally receive any EVT, with odds being greater for older ages and presence of motor deficits at presentation.5 The low incidence and under-recognition of AIS in the pediatric population has previously been highlighted.6 A nationwide study from Switzerland suggests that only a third of children with AIS are diagnosed within 6 hours from AIS onset, with the diagnostic delay predominately being attributed to the insufficient recognition of AIS symptoms in children.7 According to a single-center study from a Canadian pediatric center, the median time interval from symptom onset to AIS diagnosis was 22.7 hours, with in-hospital delays accounting for a median of 12.7 hours.8 In the Save ChildS Study, the median time from stroke onset to admission was 3 hours, while 8 children (11%) received EVT treatment despite presenting with unknown symptom onset time.3,4 Although perfusion imaging is reported to be feasible in pediatric AIS and may help identify salvageable tissue in the extended time window, penumbral thresholds for children may differ from adults.9 Further studies are therefore needed to explore extended time criteria for EVT in this unique population. It should also be highlighted that even though the vast majority of patients in the Save ChildS Study presented within 4.5 hours from symptom onset, only 16 (21.9%) received bridging therapy, with intravenous thrombolysis preceding EVT. This percentage, which is much lower than the corresponding of adult AIS population receiving combined intravenous thrombolysis-EVT treatment,10 could potentially be attributed to the uncertainty of AIS diagnosis in children,7,8 and also to the lack of robust evidence on the efficacy and safety of intravenous thrombolysis treatment for the pediatric population.11 Bridging intravenous thrombolysis with EVT seems, however, to be feasible in achieving reperfusion for patients with pediatric AIS due to persisting LVO.12 In the present secondary analysis of the Save ChildS study, authors suggest that A Direct Aspiration First Pass Technique was neither associated with the rate of successful recanalization nor with periprocedural complications compared with other EVT approaches.4 Despite the lack of difference in patient baseline characteristics and clinical outcomes, the proportion of any complication observed was higher in the A Direct Aspiration First Pass Technique group compared with the stent retriever group (13.1% versus 0%).4 This difference can be a play of chance due to the very limited number of patients in the A Direct Aspiration First Pass Technique group (7 patients, 10% of the total population) and/or potentially confounded by selection bias, given that device selection was left at the discretion of the interventionalists.4 However, it should be highlighted that contrary to the adult population atherosclerosis is negligible as a stroke mechanism in the pediatric population13 and thus the possibility of different safety outcomes with A Direct Aspiration First Pass Technique due to the higher prevalence of red-clot cardioembolism in the pediatric population with LVO14 deserves further investigation. Save ChildS investigators present the most compelling evidence to date favoring EVT treatment with currently available first-line devices for children with AIS due to an LVO, reporting no difference in complication rates between different age groups. Due to the apparent limitations of the retrospective study design and limited sample size, these observations require further independent validation by prospective cohort studies and international stroke registries. Taking into account that the TIPS trial (Thrombolysis in Pediatric Stroke) failed in recruiting patients due to prolonged hospital arrivals, diagnostic delays, and lack of established pediatric AIS programs,15 the implementation of dedicated randomized-controlled clinical trials evaluating the utility of EVT in the pediatric population seems unlikely without first proceeding with the establishment of acute stroke centers with multidisciplinary teams and stroke alert systems for children presenting with suspected AIS.16 None The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. Guest Editor for this article was Georgios Tsivgoulis, MD.
更新日期:2020-03-02

 

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