Thrombectomy Versus Medical Management for Pediatric Arterial Ischemic Stroke With Large Baseline Infarct

Kartik D Bhatia; Prakash Muthusami; Carmen Parra-Farinas; Elizabeth Pulcine; Samyami Chowdhury; Nomazulu Dlamini; Ian Andrews; Sachin Gupta; Richard Webster; Christopher Troedson; Russell C Dale; Ferdinand Miteff; Christina Miteff; Christine K Fox; Adam A Dmytriw; Sarah Lee; Jens Fiehler; Todd Abruzzo; Lisa Pabst; Stuart Fraser; Lisa R Sun; Grégoire Boulouis; Thi Dan Linh Nguyen-Kim; Moritz Wildgruber; Peter B Sporns

doi:10.1161/STROKEAHA.125.050993

Thrombectomy Versus Medical Management for Pediatric Arterial Ischemic Stroke With Large Baseline Infarct

Stroke. 2025 Jun 25. doi: 10.1161/STROKEAHA.125.050993. Online ahead of print.

Authors

Kartik D Bhatia¹, Prakash Muthusami², Carmen Parra-Farinas², Elizabeth Pulcine³, Samyami Chowdhury³, Nomazulu Dlamini³, Ian Andrews⁴, Sachin Gupta^{1

5}, Richard Webster^{1

5}, Christopher Troedson^{1

5}, Russell C Dale^{1

5}, Ferdinand Miteff⁶, Christina Miteff⁷, Christine K Fox^{8

9}, Adam A Dmytriw¹⁰, Sarah Lee¹¹, Jens Fiehler¹², Todd Abruzzo¹³, Lisa Pabst¹⁴, Stuart Fraser¹⁵, Lisa R Sun¹⁶, Grégoire Boulouis^{17

18}, Thi Dan Linh Nguyen-Kim¹⁹, Moritz Wildgruber²⁰, Peter B Sporns^{12

19

21}

Affiliations

¹ Children's Hospital at Westmead Clinical School, University of Sydney, New South Wales, Australia (K.D.B., S.G., R.W., C.T., R.C.D.).
² Division of Paediatric Interventional Neuroradiology (P.M., C.P.-F.), Hospital for Sick Children, Toronto, Ontario, Canada.
³ Division of Neurology (E.P., S.C., N.D.), Hospital for Sick Children, Toronto, Ontario, Canada.
⁴ Department of Neurology, Sydney Children's Hospital, Randwick, New South Wales, Australia (I.A.).
⁵ T.Y. Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, New South Wales, Australia (S.G., R.W., C.T., R.C.D.).
⁶ Department of Neurology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia (F.M.).
⁷ Department of Neurology, John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia (C.M.).
⁸ Department of Neurology (C.K.F.), University of California San Francisco.
⁹ Department of Pediatrics (C.K.F.), University of California San Francisco.
¹⁰ Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston (A.A.D.).
¹¹ Division of Child Neurology, Department of Neurology, Stanford University, CA (S.L.).
¹² Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F., P.B.S.).
¹³ Department of Radiology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix Children's Hospital, AZ (T.A.).
¹⁴ Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (L.P.).
¹⁵ Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston (S.F.).
¹⁶ Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD (L.R.S.).
¹⁷ Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France (G.B.).
¹⁸ French Center for Pediatric Stroke, Paris (G.B.).
¹⁹ Department of Radiology and Neuroradiology, Stadtspital Zürich, Switzerland (T.D.L.N.-K., P.B.S.).
²⁰ Department of Radiology, LMU University Hospital, LMU Munich, Germany (M.W.).
²¹ Department of Neuroradiology, University Hospital Basel, Switzerland (P.B.S.).

PMID: 40557480
DOI: 10.1161/STROKEAHA.125.050993

Abstract

Background: Multiple recent randomized trials have demonstrated the benefit of thrombectomy over medical management alone in adult patients with large vessel occlusion (LVO) stroke and large infarct on baseline imaging. Cohort studies have also identified improved functional outcomes in pediatric patients who received thrombectomy. However, the role of thrombectomy in pediatric stroke with large baseline infarct remains uncertain.

Methods: A case-control study was undertaken using pooled data from 3 cohort studies of pediatric stroke (Save ChildS, Save ChildS Pro, Pediatric LVO Stroke Study). Pediatric patients of age 1 to 18 years with acute anterior circulation LVO stroke presenting within 24 hours since last seen well with an Alberta Stroke Program Early Computed Tomography (CT) Score of 0 to 5 on CT or magnetic resonance imaging were included. Isolated M2 occlusion or focal cerebral arteriopathy-inflammatory subtype cases were excluded. Thrombectomy-treated patients were compared with patients who received medical management alone. The primary clinical outcome was the pediatric modified Rankin Scale score at 90 days, compared between groups using ordinal logistic regression.

Results: Of 56 pediatric patients with anterior circulation LVO and low Alberta Stroke Program Early CT Score presenting between January 1, 2000 and August 31, 2023 from 45 centers across Europe, North America, and Australia, 40 patients were eligible for inclusion (female: n=14, 35.0%; mean age, 9.1 years; range, 1.5-17; SD, 5.27). Thrombectomy-treated patients (n=24) had significantly better pediatric modified Rankin Scale scores at 90 days than medical management alone patients (n=16; odds ratio, 3.68 [95% CI, 1.11-12.21]; P=0.034). There was no significant difference between groups in the rate of symptomatic intracranial hemorrhage (P=0.806).

Conclusions: In this multicentre case-control study, pediatric patients (age, 1-18 years) with anterior circulation LVO stroke and low Alberta Stroke Program Early CT Score who received thrombectomy had significantly better functional outcomes than those treated with medical management alone. Exclusion of pediatric patients from thrombectomy based on low Alberta Stroke Program Early CT Score alone may not be appropriate.

Keywords: case-control studies; child; intracranial hemorrhage; stroke; thrombectomy.