E-070 Endovascular treatment in a paediatric patient with thrombus extending from right internal carotid artery to right middle cerebral artery
Authors: Sangha R , Nayyar S , Sood A , Eksioglu Y , Lodi Y 
Published: July 2013

Introduction

Paediatric stroke leads to significant morbidity and mortality. Approximately10–25% of children with a stroke will die, up to 25% of children will have a recurrence, and approximately 66% will have persistent neurological deficits. Hyperacute ischaemic stroke treatment modalities in paediatric patients has been a topic of controversy due to limited data. With limited studies available to determine the efficacy of such treatment more data is required before the use of intra-arterial tissue plasminogen activator (IA tPA) or mechanical retrieval devices will become widely accepted treatment vehicles.

Case

The patient was a 8-year-old male with a past medical history significant for congenital heart disease, including transposition of the great arteries, Epstein anomaly of the tricuspid valve, and status post correction of co-arctation of the aorta along with VSD closure who presented to the hospital after having sudden onset of left sided weakness and dysarthria. Upon presentation in the emergency department he was ascertained to have a NIH stroke scale of 11 and CT showed a dense right MCA sign. After evaluation it was felt the patient would benefit from endovascular therapy and was subsequently taken to the interventional suite approximately 3.5 hours after symptom onset. Prior to therapy the patient had 150 mg aspirin administered rectally.

Cerebral angiography of the head demonstrated right ICA terminus occlusion in which thrombus extending from the right ICA into the right MCA and anterior cerebral artery. Using transfemoral approach, a 14 compatible microcatheter was placed in the MCA and 2 mg IA tPA delivered prior to perform thrombectomy. A Solitaire 4x20 mm thrombectomy device was used to remove clots which resulted in complete recanalisation Following the procedure he was transported to the paediatric ICU where he was monitored and MRI scan one day and seven days following procedure showed restricted diffusion in the ACA and MCA territory without haemorrhagic transformation. The patient was discharged from rehabilitation with a NIHSS of 6 with no deficits in cognitive function.

Discussion

To our knowledge this is the first presented paediatric case of a large burden thrombus extending from the internal carotid artery to the MCA and ACA with subsequent endovascular thrombectomy using Solitaire thrombectomy device. Significant clot burden such as in the presenting case will require more aggressive therapy modalities such as mechanical clot retrieval. The continuing assessment and evaluation of extensive paediatric stroke through the use of mechanical clot retrieval should be given merit as it has the potential for positive outcomes. The patient tolerated the procedure well and hemispheric stroke damage was mitigated to limited regions of the ACA and MCA territories. Given the extensive thrombus leading to limited flow the patient could have suffered a malignant MCA/ACA territorial infarct which carries a high degree of morbidity and mortality. This case highlights the requirement for establishing guidelines in the paediatric population for the use of mechanical thrombectomy as well as IA tPA administration.

Disclosures

R. Sangha: None. S. Nayyar: None. A. Sood: None. Y. Eksioglu: None. Y. Lodi: None.