scholarly journals Clinical diffusion mismatch to select pediatric patients for embolectomy 6 to 24 hours after stroke

Neurology ◽  
2020 ◽  
pp. 10.1212/WNL.0000000000011107
Author(s):  
Peter B. Sporns ◽  
Marios-Nikos Psychogios ◽  
Ronald Straeter ◽  
Uta Hanning ◽  
Jens Minnerup ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Pediatric Patients ◽  
Time Window ◽  
Secondary Analysis ◽  
National Institutes Of Health ◽  
Arterial Ischemic Stroke ◽  
Neurological Outcomes ◽  
Endovascular Recanalization ◽  
Study Population

ObjectiveTo determine whether thrombectomy is safe in children up to 24 hours after onset of symptoms when selected by mismatch between clinical deficit and infarct.MethodsA secondary analysis of the Save ChildS Study (01/2000–12/2018) was performed, including all pediatric patients (<18 years), diagnosed with Arterial Ischemic Stroke who underwent endovascular recanalization at 27 European and United States stroke centers. Patients were included if they had a relevant mismatch between clinical deficit and infarct.ResultsTwenty children with a median age of 10.5 years (interquartile range; IQR 7–14.6) were included. Of those 7 were male (35%) and median time from onset to thrombectomy was 9.8 hours (IQR 7.8–16.2). Neurologic outcome improved from a median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score of 12.0 (IQR, 8.8–20.3) at admission to 2.0 (IQR, 1.2–6.8) at day 7. Median modified Rankin Scale (mRS) score was 1.0 (IQR, 0–1.6) at 3 months and 0.0 (IQR, 0–1.0) at 24 months. One patient developed transient peri-interventional vasospasm; no other complications were observed. A comparison of the mRS to the mRS in the DAWN and DEFUSE 3 trials revealed a higher proportion of good outcomes in the pediatric compared to the adult study population.ConclusionsThrombectomy in pediatric ischemic stroke in an extended time window of up to 24 hours after onset of symptoms seems safe and neurological outcomes are generally good, if patients are selected by a mismatch between clinical deficit and infarct.Classification of evidenceThis study provides Class IV evidence that for children with acute ischemic stroke with a mismatch between clinical deficit and infarct size, thrombectomy is safe.

scholarly journals Does Device Selection Impact Recanalization Rate and Neurological Outcome?

Stroke ◽  
2020 ◽  
Vol 51 (4) ◽  
pp. 1182-1189 ◽  
Author(s):  
Peter B. Sporns ◽  
Ronald Straeter ◽  
Jens Minnerup ◽  
Heinz Wiendl ◽  
Uta Hanning ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Neurological Outcome ◽  
Pediatric Patients ◽  
Stent Retriever ◽  
Complication Rates ◽  
Arterial Ischemic Stroke ◽  
First Line ◽  
Outcome Parameters ◽  
Neurological Outcomes ◽  
Device Selection

Background and Purpose— The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters. Methods— The Save ChildS cohort study (January 2000–December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated. Results— Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters. Conclusions— Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection. Registration— URL: https://www.drks.de/ ; Unique identifier: DRKS00016528.

Abstract 174: Headache Presentation in Childhood Arterial Ischemic Stroke Differs by Arteriopathy Subtype

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lori L Billinghurst ◽  
Nancy K Hills ◽  
Laura Jastrzab ◽  
Max Wintermark ◽  
Gabrielle A deVeber ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Secondary Analysis ◽  
Arterial Ischemic Stroke ◽  
Vascular Effects ◽  
Afferent Activation ◽  
Significant Difference ◽  
Acute Headache ◽  
Radiographic Classification ◽  
Pathophysiologic Mechanisms

Introduction: Headache is common at onset of arterial ischemic stroke (AIS), with rates between 10-50%. Adult studies suggest that headache prevalence relates to stroke etiology, with highest rates observed in dissection. We hypothesized that children with arteriopathy-related stroke may have higher rates of headache than those without. Methods: Children (29 days -18 years) with AIS enrolled in the prospective, international Vascular Effects of Infection in Pediatric Stroke (VIPS) study were analyzed for presence of headache at stroke ictus. Cases were subjected to a rigorous, centralized process for diagnostic confirmation of AIS and radiographic classification of arteriopathy as definite, possible or absent. Site investigators abstracted data from medical records regarding stroke presentation details. Headache at stroke ictus was classified as present, absent or unclear. Results: We included all 355 VIPS cases in this secondary analysis. Headache was uncommon in subjects < 3 yo (5/90, 6%) but was present in nearly half of those ≥ 3 yo (108/265, 46%). Excluding those with an unclear headache presentation (n=31), there was no significant difference in headache at stroke ictus in children ≥ 3 yo with definite (46/92, 50%), possible (15/24, 63%) or absent (60/118, 51%) arteriopathy (p=0.53). However, in those with definite arteriopathy, a difference was found in sub-classification, with headache prevalence highest in dissection and transient cerebral arteriopathy of childhood (TCA) (70% each) (p>0.001). Acute headache was uncommon in children with moyamoya (12%). Conclusion: No difference was found in headache prevalence in children with and without definite or possible arteriopathy. However, in children with definite arteriopathy, headache was more common in TCA and dissection. This may reflect a higher degree of nociceptive afferent activation in these childhood AIS subtypes and may provide clues to underlying pathophysiologic mechanisms.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

scholarly journals Risk factors, types and outcomes of arterial ischemic stroke in Polish pediatric patients: a retrospective single-center study

2021 ◽  
Vol 17 (1) ◽  
pp. 62-70 ◽  
Author(s):  
Beata Sarecka-Hujar ◽  
Ilona Kopyta ◽  
Dorota Raczkiewicz
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Pediatric Patients ◽  
Age At Onset ◽  
Neurological Complications ◽  
Arterial Ischemic Stroke ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Post Stroke ◽  
Normal Outcome

IntroductionVarious neurological complications may occur as a consequence of arterial ischemic stroke (AIS) and have an impact on daily activity of the patients, costs of their medical care and rehabilitation. The aim of this study was to analyze risk factors, stroke symptoms and post-stroke consequences in Polish pediatric patients depending on stroke subtype.Material and methodsWe retrospectively reviewed 77 children under the age of 18 years following their first AIS. Patients were white, Polish Caucasians, recruited in the Department of Pediatric Neurology at the Medical University of Silesia in Katowice (Poland). Statistical analysis was performed using Statistica 12.0.ResultsGender differed significantly between stroke subgroups (p = 0.030). The presence of focal cerebral arteriopathy (FCA) and chronic diseases was associated with type of AIS (p = 0.003 and p = 0.050, respectively). An outcome without neurological deterioration (normal outcome) was observed in 43% of children with lacunar anterior circulation infarct (LACI). Hemiparesis was present in almost all children with total anterior circulation infarct (TACI), in two thirds of children with partial anterior circulation infarct (PACI) and in almost 50% of children with LACI or posterior circulation infarct (POCI). In every child with hemiplegia the stroke symptom evolved into hemiparesis at follow-up. Additionally, patients with a normal outcome were older at the time of AIS than those with at least one neurological consequence (OR = 0.894, p = 0.034).ConclusionsThe presence and number of neurological outcomes depend on stroke subtypes. A relation between the presence of post-stroke deficits and age at onset was observed. The odds of deficit after ischemic stroke decreases by an average of 10.6% if the child is 1 year older at the time of AIS.

scholarly journals Towards a Consensus-Based Classification of Childhood Arterial Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (2) ◽  
pp. 371-377 ◽  
Author(s):  
Timothy J. Bernard ◽  
Marilyn J. Manco-Johnson ◽  
Warren Lo ◽  
Mark T. MacKay ◽  
Vijeya Ganesan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Arterial Ischemic Stroke

Incidence of Aspirin ’Resistance’ as Determined Using the PFA-100 in Pediatric Patients with Arterial Ischemic Stroke.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1882-1882 ◽  
Author(s):  
Margaret L. Rand ◽  
Sylvain Lanthier ◽  
Trish Domi ◽  
Dewi Clark ◽  
Anthony K.C. Chan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Platelet Function ◽  
Pediatric Patients ◽  
Aspirin Resistance ◽  
Current Treatment ◽  
Test Time ◽  
Healthy Children ◽  
Arterial Ischemic Stroke ◽  
Normal Range ◽  
Maximum Test

Abstract A significant benefit of aspirin (ASA) has been demonstrated in the prevention of arterial thrombotic events in high-risk adult patients. Despite ASA therapy, recurrence of thromboembolic events, or treatment failure, has been reported in 10–20% of patients, and this has been termed ASA ’resistance’. This term has also been applied to the failure of ASA to affect ASA-dependent laboratory tests. As there is little information on ASA ’resistance’ in children, we examined the efficacy of ASA treatment on platelets from pediatric stroke patients using the PFA-100. Pediatric arterial ischemic stroke afflicts 2–3 children per 100,000 per year, and is associated with recurrent arterial ischemic stroke or transient ischemic attack in 20–40% of cases. Current treatment includes ASA prophylaxis (3 – 5 mg/kg/day) to inhibit platelet function and prevent recurrence, but it is not known whether this ASA dosing regimen is adequate to inhibit platelet function. Our study population consisted of 95 consecutive children with an index arterial ischemic stroke at mean age 5.9 ± 4.8 yrs (range: 0.1 – 17.0 yrs) on active ASA therapy (2.9 ± 1.2 mg/kg/day). Citrated blood samples were obtained at mean age 9.8 ± 4.8 yrs (range: 0.9 – 19 yrs), and were used to measure primary, platelet-related hemostasis in the high-shear PFA-100 system; closure times (CTs) were determined with the collagen/epinephrine cartridge that is sensitive to ASA’s inhibition of thromboxane A2 formation via platelet cyclo-oxygenase 1. The mean CT for all 95 patients was 244 ± 68.1 sec, which is greater than 163 sec, the upper limit of the normal range that we have previously determined for healthy children. The majority of patients, 75/95 (79%), had prolonged CTs (172 sec to > 300 sec), indicating inhibition of platelet function by ASA, and they were thus responsive to ASA therapy. 45 of the 75 ASA responders (63%) had CTs > 300 sec, i.e. CTs greater than the maximum test time of 300 sec, demonstrating aperture non-closure. The remaining 20/95 patients (21%) were ASA ’resistant’, as they did not respond to ASA therapy, having CTs (93 – 163 sec) within the normal range. Mean ASA dosage did not differ between ASA responders (2.8 ± 1.2 mg/kg/day) and ASA ’resistant’ patients (3.0 ± 1.4 mg/kg/day). 6 of the ASA ’resistant’ patients had their ASA dosage increased, and on repeat PFA-100 testing, 5/6 showed increased CTs > 163 sec. In conclusion, in children with arterial ischemic stroke, the majority, 79%, demonstrate inhibition of platelet function, as determined using the PFA-100, by ASA therapy at a mean dose of 2.9 mg/kg/day. The reason for the lack of inhibition of platelet function in 21% of pediatric patients, whether increased ASA dosage or alternative anti-platelet agents (e.g. clopidogrel) should be used in ASA ’resistant’ patients, and the relationship between ASA ’resistance’ and recurrence of arterial thrombotic events in children require further studies.

scholarly journals Does the Occurrence of Particular Symptoms and Outcomes of Arterial Ischemic Stroke Depend on Sex in Pediatric Patients?—A Pilot Study

2020 ◽  
Vol 10 (11) ◽  
pp. 881
Author(s):  
Ilona Kopyta ◽  
Anna Dobrucka-Głowacka ◽  
Agnieszka Cebula ◽  
Beata Sarecka-Hujar
Keyword(s):  
Ischemic Stroke ◽  
Medical Records ◽  
Pediatric Patients ◽  
Arterial Ischemic Stroke ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Central Type ◽  
Post Stroke ◽  
Stroke Subtypes ◽  
Posterior Circulation Infarct

Arterial ischemic stroke (AIS) in childhood is reported to occur more frequently in boys, which may lead to the assumption that the prevalence of post-stroke deficits is sex related. The present study aimed to evaluate sex-related differences in functional outcomes (hemiparesis, seizures, aphasia, and motor disturbances other than hemiparesis) in pediatric patients with AIS. A total of 89 children (52 boys and 37 girls; mean age at stroke onset: 8.4 ± 5.6 years) were evaluated retrospectively based on data from medical records. The patients were divided into subgroups according to age (i.e., infants and toddlers, children, and adolescents), stroke subtype (i.e., lacunar anterior circulation infarct (LACI), total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), posterior circulation infarct (POCI)) and stroke location (i.e., anterior stroke, posterior stroke). Significant differences in the prevalence of stroke subtypes between girls and boys were observed (p = 0.034). POCI stroke were found to be more frequent in boys than in girls (OR = 8.57 95%CI 1.05–70.23, p = 0.023). Males predominated in the total group and in all analyzed age subgroups. The proportions of boys within the subgroups according to stroke subtype were extremely high for the POCI and TACI stroke subgroups. On the other hand, girls predominated in the LACI stroke subgroup. Frequency of central type facial nerve palsy and other symptoms of AIS were found to significantly differ between male subgroups according to stroke subtype (p = 0.050 and p < 0.001, respectively), as well as between children with anterior stroke and those with posterior stroke (p = 0.059 and p < 0.001, respectively). Post-stroke seizures appeared significantly more commonly in girls with TACI and POCI stroke than in girls with LACI and PACI stroke (p = 0.022). In turn, the prevalence of post-stroke hemiparesis differed between stroke subtypes in boys (p = 0.026). In conclusion, sex may have an impact in predisposing to a certain type of AIS in the patient. Post-stroke seizure may be related to stroke subtype in girls and hemiparesis in boys. However, further studies are needed to confirm the results.

scholarly journals Endovascular Recanalization by Mechanical Thrombectomy in Tandem Extracranial and Intracranial Occlusive Lesion in Acute Ischemic Stroke is Still a Therapeutic Challenge: A Case Report

2019 ◽  
Vol 5 (1) ◽  
pp. 90-94
Author(s):  
Sirajee Shafiqul Islam ◽  
Kazi Mohibur Rahman ◽  
Sharif Uddin Khan ◽  
Dewan Md Elyas ◽  
Khairul Kabir Patwary ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Case Report ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
The Body ◽  
National Institutes Of Health ◽  
Endovascular Recanalization ◽  
Occlusive Lesion ◽  
The Right

A 55-year-old male presented with complete left-sided weakness of the body with a National Institutes of Health Stroke Scale (NIHSS) 15 and Alberta Stroke Program Early Computed Tomography (ASPECT) score 8 and occlusion of the right middle cerebral artery (MCA) in the M1 segment on Computed Tomography Angiography (CTA). Intravenous thrombolysis (IVT) was not performed as symptoms developed at sleep. Mechanical Thrombectomy was performed after 4.5 hours of the symptom onset with recanalization of Thrombolysis in Cerebral Infarction (TICI classification 2b). Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 90-94

CT Hypoperfusion–Hypodensity Mismatch to Identify Patients With Acute Ischemic Stroke Within 4.5 Hours of Symptom Onset

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012891
Author(s):  
Peter B Sporns ◽  
André Kemmling ◽  
Heike Minnerup ◽  
Lennart Meyer ◽  
Christos Krogias ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Predictive Value ◽  
Interobserver Agreement ◽  
Time Window ◽  
Stroke Onset ◽  
Class Iii ◽  
Predictive Values

ObjectiveTo test the hypothesis that CT hypoperfusion-hypodensity mismatch identifies patients with ischemic stroke within 4.5 hours of symptom onset.MethodsWe therefore performed the “retrospective multicenter hypoperfusion-hypodensity mismatch for the identification of patients with stroke within 4.5 hours study” of patients with acute ischemic stroke and known time of symptom onset. The predictive values of hypoperfusion-hypodensity mismatch for the identification of patients with symptom onset within 4.5 hours were the main outcome measure.ResultsOf 666 patients, 548 (82.3 %) had multimodal CT within 4.5 hours and 118 (17.7%) beyond. Hypoperfusion-hypodensity mismatch was visible in 516 (94.2%) patients with symptom onset within and in 30 (25.4%) patients beyond 4.5 hours. CT hypoperfusion-hypodensity mismatch identified patients within 4.5 hours of stroke onset with 94.2% (95% CI: 91.9-95.8%) sensitivity, 74.6% (95% CI: 66.0-81.6%) specificity, 94.5% (95% CI: 92.3-96.1%) positive predictive value, and 73.3% (95% CI: 64.8-80.4%) negative predictive value. Interobserver agreement for hypoperfusion-hypodensity mismatch was substantial (κ=0.61, 95% CI 0.53-0.69).ConclusionsIn conclusion, patients with acute ischemic stroke with absence of a hypodensity on native CT within the hypoperfused core lesion on perfusion CT (hypoperfusion-hypodensity mismatch) are likely to be within the time window of thrombolysis. Applying this method may guide the decision to use thrombolysis in patients with unknown time of stroke onset.Classification of EvidenceThis study provides Class III evidence that CT hypoperfusion-hypodensity mismatch identifies patients with stroke within 4.5 hours of onset.

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