Abstract 364: Pediatric Case of COVID‐Related Serial Large Vessel Occlusions Treated with Repeated Mechanical Thrombectomy
Authors: Shah R. , Sheikh M. , Bartolina R. , Cuellar H. , Chokhawala H. , Siddiqui A. , ansari J. 
Published: January 2025

Introduction
Infection with the SARS‐CoV‐2 virus, leading to the disease entity Coronavirus disease 2019 (COVID‐19), may be associated with several systemic sequelae, including COVID‐19‐induced hypercoagulability. Such a state may induce thrombus formation and ensuing acute ischemic stroke (AIS) from a large vessel occlusion (LVO). Herein, mechanical thrombectomy (MT) has been shown to be a highly effective therapeutic option for eligible adults with LVO strokes. However, given the relative rarity of AIS due to LVO in pediatric patients, MT as a therapeutic modality is not well defined in this population.

Materials/Methods
Case report

Results
The present case is that of an 11‐year‐old male with an extensive contributory medical history presenting twice over a period of 5 months for multiple LVOs. The patient was born with congenital complete heart block, given maternal Sjogren's syndrome, and underwent epicardial pacemaker implantation at 1 month of age, with replacement thereof in 2016. Serial cardiological follow up in the history revealed possible pacemaker‐induced cardiomyopathy with resultant dilated cardiomyopathy necessitating medical management. The patient's first presentation for stroke was in 2/2023 with a classic left middle cerebral artery (L MCA) syndrome constituting a National Institute of Health Stroke Scale (NIHSS) of 16; computed tomography of the head (CTH) findings of L MCA infarction and Alberta Stroke Program Early CT Score (ASPECTS) of 9; and computed tomography angiography (CTA) findings of L M1 occlusion. Intravenous thrombolysis was withheld at this encounter and the patient underwent MT with Thrombolysis in Cerebral Infarction (TICI) 2C reperfusion. Further history revealed COVID‐19 infection one week prior and echocardiogram during admission revealed features of acute systolic heart failure, likely due to COVID‐19 induced myocarditis. The patient experienced significant symptomatic recovery over this hospital stay, being discharged home on warfarin 5mg daily and outpatient follow up.
The patient presented again in 7/2023 with initial cortical symptoms and dilated right pupil quickly evolving to unresponsiveness, constituting an NIHSS of 23. Work up revealed an unremarkable CTH but with basilar artery occlusion on CTA. The patient received intravenous thrombolysis with alteplase and was subsequently taken for MT, with TICI 3 reperfusion. Echocardiogram at this admission revealed decreased ejection fraction and a lesion in the anterior free wall of the left ventricle suspicious for thrombus. Evaluation by physical/occupational therapy deemed the patient appropriate for inpatient physical rehabilitation, to where he was subsequently discharged with medical recommendations of aspirin and apixaban, the latter replacing his previous warfarin.

Conclusion
This is an extremely rare case of a pediatric patient developing recurrent LVO's, likely secondary to COVID infection, undergoing successful MT on both occasions. This case illustrates the potential for MT as a valuable treatment option in pediatric AIS. Despite the controversial aspect of pursuing multiple thrombectomies for treatment, especially given the rarity of AIS due to LVO in the pediatric population, this case provides an example of MT producing a favorable outcome, illustrating potential therapeutic viability.