Retrospective analysis supports off-label thrombectomy in childhood stroke

A retrospective, multicentre cohort study has shown that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults, supporting clinicians’ off-label practice of thrombectomy in paediatric patients, in the absence of high-level evidence.

Between 2000 and 2018, 73 children (51 percent boys; median age, 11.3 years; age range, 0.7 to 18.0 years) from 27 participating centres were included in the retrospective study. Median paediatric National Institutes of Health Stroke Scale (pedNIHSS) score on admission was 14.0 (interquartile range [IQR], 9.2 to 20.0), improving to a median of 5.0 (IQR, 2.2 to 8.0) 12 to 24 hours after thrombectomy and 4.0 (IQR, 2.0 to 7.3) at day 7. [JAMA Neurol 2019; doi: 10.1001/jamaneurol.2019.3403] “The short-term neurologic improvement of our study population showed a similar pattern to that observed in the adult trials,” commented the researchers. [Lancet 2016;387:1723-1731]

The median modified Rankin scale (mRS) score at discharge was 1.0 (IQR, 0.2 to 2.0), and was 1.0 (IQR, 0 to 1.6) after 6 months and 1.0 (IQR, 0 to 1.0) after 24 months. In addition, the median Paediatric Stroke Outcome Measure (PSOM) score was 1.0 (IQR, 0 to 2.0) at discharge and 0.5 (IQR, 0 to 1.0) at 6 months and 24 months after the intervention. “The long-term neurologic outcomes were good in most patients,” commented the researchers.

The incidence of periprocedural complications was low, with transient vasospasm being angiographically detected in 5 percent of patients. In all cases, the vasospasms seemed to resolve after administration of nimodipine and were without any clinical sequelae. In addition, one patient with a pre-existing heart anomaly died of cardiac arrest after complete recanalization of the M1 segment of the middle cerebral artery occlusion. No vascular complications, such as arterial dissection, periprocedural thrombosis, or puncture site complications were reported.

Postinterventional complications that were reported included symptomatic intracerebral haemorrhage in one patient, and malignant infarction followed by decompressive hemicraniectomy in three patients. “The complication rates were low in children undergoing mechanical recanalization treatment, with relevant intracerebral haemorrhage occurring in one patient only,” wrote the researchers.

“Endovascular thrombectomy in paediatric patients with ischaemic stroke and large-vessel occlusion is feasible, as most (87 percent) patients underwent successful recanalization,” wrote the researchers.

“This study may support clinicians’ practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence,” they concluded.