medwireNews: Pediatric patients with large- or medium-vessel occlusion strokes have better functional outcomes when given endovascular thrombectomy in addition to best medical treatment compared with best medical treatment alone, prospective study findings indicate.
Peter Sporns (University Hospital Basel, Switzerland) and co-investigators say that the results of the Save ChildS Pro registry study add “to the growing evidence that children with large-vessel occlusion stroke have superior outcomes when treated with endovascular thrombectomy.”
The analysis included 208 children (55% boys) aged between 28 days and 18 years presenting with arterial ischemic stroke caused by a large-vessel or medium-vessel occlusion at 45 centers in 12 countries.
Of these, 117 underwent endovascular thrombectomy plus best medical treatment, including systemic thrombolysis, platelet inhibition, and anticoagulation, and 91 received best medical treatment alone.
The researchers report in The Lancet Child & Adolescent Health that, compared with patients who received best medical treatment alone, those treated with endovascular thrombectomy were significantly older (median age 11 versus 6 years) and had significantly more severe stroke at the time of hospital admission (median Pediatric National Institutes of Health Stroke Scale [PedNIHSS] score 14 versus 9 points).
In spite of this, patients who underwent endovascular thrombectomy had significantly better functional outcomes at 90 days after stroke than those who only received best medical treatment.
Specifically, the modified Rankin Scale (mRS) score, which ranges from 0 to 6 points with higher scores representing greater disability, increased from 0 points at pre-stroke baseline to 1 point at 90 days in patients given endovascular thrombectomy and from 0 points to 2 points among those who did not receive the procedure. The between-group difference in the change from baseline was statistically significant.
Secondary outcomes, namely the change in median PedNIHSS score from hospital admission to discharge and the 90-day pediatric stroke outcome measure score (PSOM), were also significantly better in the endovascular thrombectomy group than in the best medical care group and the effect on both primary and secondary outcomes was maintained after propensity score matching for age, sex, and initial stroke severity.
“The consistency of these findings after propensity score matching […] emphasises the value of endovascular thrombectomy and represents a high-quality approach to analysing observational registry data in the absence of a randomised trial,” Sporns et al remark.
They note that the safety and efficacy of endovascular thrombectomy in patients with arteriopathies is a “major concern.” In the subgroup with suspected focal cerebral arteriopathy, the 90-day median mRS score did not differ by treatment, at 2 points among the 18 patients who received endovascular thrombectomy and the 33 patients who received best medical treatment alone.
The authors suggest: “This might reflect the smaller sample size and heterogeneity of this focal cerebral arteriopathy subgroup, or potentially a more subtle yet still clinically relevant effect of endovascular thrombectomy in patients with focal cerebral arteriopathy.”
However, the change in median PedNIHSS score from hospital admission to discharge and the median 90-day PSOM score in this subgroup were both significantly better with versus without endovascular thrombectomy.
There were six (5%) deaths within 90 days in the endovascular thrombectomy group and four (5%) in the best medical treatment group. Nonsymptomatic intracranial hemorrhage during treatment affected nine (8%) and six (7%) patients, respectively, while one (1%) patient in the endovascular thrombectomy group developed a symptomatic intracranial hemorrhage.
Sporns and team conclude that their findings “provide strong support for endovascular thrombectomy in children with arterial ischaemic stroke and medium or large arterial occlusion, which will inform future guidelines.”
They add: “Adequate training of all physicians involved in acute stroke care, development of clear selection criteria for endovascular thrombectomy, and standardisation of interventional procedures are crucial to maintain these positive treatment effects.”
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Lancet Child Adolesc Health 2024; doi:10.1016/ S2352-4642(24)00233-5