Neurointervention.  2023 Jul;18(2):140-144. 10.5469/neuroint.2023.00045.

Mechanical Thrombectomy in a 12-Month-Old Infant with Acute Ischemic Stroke Possibly due to Internal Carotid Artery Dissection: A Case Report

• Hezarkhani LA
• Abdollahifard S
• Mirbolouk MH
• Hooshmand S
• Mowla A
• Baharvahdat H

• KMID: 2543370
• DOI: http://doi.org/10.5469/neuroint.2023.00045

Abstract

Stroke in children is a rare but devastating disease. Although endovascular treatment has been reported to be safe and effective in the treatment of stroke with large vessel occlusion in this population, there are still limitations and controversies. In this case report, we describe a 12-month-old girl who was admitted to the hospital with acute onset of left-sided hemiplegia and confusion, which turned out to be due to a large infarct in the right middle cerebral artery territory, possibly caused by dissection of the right cervical internal carotid artery. Aspiration thrombectomy was successfully performed, and the patient was able to walk a few steps and raise her left upper extremity at the 12-month follow-up. The aspiration-only technique in thrombectomy may be safe and technically feasible to treat acute ischemic stroke with large vessel occlusion in children as young as 12 months, although large-volume prospective studies are needed.

Keyword

Stroke; Infant; Aspiration thrombectomy; Arterial dissection

Figure

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  Fig. 1. (A) Magnetic resonance imaging of the brain without contrast, diffusion-weighted imaging, and apparent diffusion coefficient (ADC) map, showing diffusion restriction with ADC map correlation in the right middle cerebral artery (MCA) territory suggestive of acute infarction. (B) Lateral view: Right internal carotid artery (ICA) flame-shaped tapering above the carotid bulb is suggestive of occlusive right ICA dissection. Right intracranial ICA partially supplied by retrograde flow of the ophthalmic artery. Arrows indicate right ICA (white long arrow) and right common carotid artery (CCA) (black long arrow). (C) Anterior view: right CCA angiogram showed right ICA dissection above the carotid bulb. Right intracranial ICA partially supplied by retrograde flow of the ophthalmic artery. Arrows indicate right ICA (white long arrow) and right CCA (black long arrow). (D) Lateral and anterior-posterior (AP) view of the right CCA angiogram after 1st pass of thrombectomy, showing right terminal ICA occlusion. (E) Final AP view angiogram of the right ICA showing complete recanalization of the right MCA vascular tree except for distal M3 branches occlusion (Thrombolysis in Cerebral Infarction [TICI] 2b). (F) Final lateral view of the right ICA angiogram showed occlusion of distal M3 branches of the right MCA (TICI 2b) (short arrows). Short arrows indicate occlusion in right MCA distal branches.

Reference

1. Shoirah H, Shallwani H, Siddiqui AH, Levy EI, Kenmuir CL, Jovin TG, et al. Endovascular thrombectomy in pediatric patients with large vessel occlusion. J Neurointerv Surg. 2019; 11:729–732.

2. Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, et al. Childhood stroke. Nat Rev Dis Primers. 2022; 8:12.

3. Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, et al. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol. 2018; 3:245–252.

4. Ganesan V, Prengler M, McShane MA, Wade AM, Kirkham FJ. Investigation of risk factors in children with arterial ischemic stroke. Ann Neurol. 2003; 53:167–173.

5. Goeggel Simonetti B, Cavelti A, Arnold M, Bigi S, Regényi M, Mattle HP, et al. Long-term outcome after arterial ischemic stroke in children and young adults. Neurology. 2015; 84:1941–1947.

6. Ganesan V, Prengler M, Wade A, Kirkham FJ. Clinical and radiological recurrence after childhood arterial ischemic stroke. Circulation. 2006; 114:2170–2177.

7. Madaelil TP, Kansagra AP, Cross DT, Moran CJ, Derdeyn CP. Mechanical thrombectomy in pediatric acute ischemic stroke: clinical outcomes and literature review. Interv Neuroradiol. 2016; 22:426–431.

8. Kaur N, Patel S, Ayanbadejo MO, Hoffman H, Akano E, Anikpezie N, et al. Age-specific trends in intravenous thrombolysis and mechanical thrombectomy utilization in acute ischemic stroke in children under age 18. Int J Stroke. 2023; 18:469–476.

9. Staby I, Krogh J, Klose M, Baekdal J, Feldt-Rasmussen U, Poulsgaard L, et al. Pituitary function after transsphenoidal surgery including measurement of basal morning cortisol as predictor of adrenal insufficiency. Endocr Connect. 2021; 10:750–757.

10. Nash M, Rafay MF. Craniocervical arterial dissection in children: pathophysiology and management. Pediatr Neurol. 2019; 95:9–18.

11. Fullerton HJ, Johnston SC, Smith WS. Arterial dissection and stroke in children. Neurology. 2001; 57:1155–1160.

12. Stence NV, Fenton LZ, Goldenberg NA, Armstrong-Wells J, Bernard TJ. Craniocervical arterial dissection in children: diagnosis and treatment. Curr Treat Options Neurol. 2011; 13:636–648.

13. Scoville J, Joyce E, Harper J, Hunsaker J, Gren L, Porucznik C, et al. A survey and analysis of pediatric stroke protocols. J Stroke Cerebrovasc Dis. 2022; 31:106661.

14. Christi AY, Suroto NS, Bajamal Z, Al Fauzi A. Primary mechanical thrombectomy for anterior circulation stroke in children: report of two cases and literature review. Int J Surg Case Rep. 2021; 89:106655.

15. Sporns PB, Kemmling A, Hanning U, Minnerup J, Sträter R, Niederstadt T, et al. Thrombectomy in childhood stroke. J Am Heart Assoc. 2019; 8:e011335.

16. Sun LR, Felling RJ, Pearl MS. Endovascular mechanical thrombectomy for acute stroke in young children. J Neurointerv Surg. 2019; 11:554–558.

17. He L, Ladner TR, Pruthi S, Day MA, Desai AA, Jordan LC, et al. Rule of 5: angiographic diameters of cervicocerebral arteries in children and compatibility with adult neurointerventional devices. J Neurointerv Surg. 2016; 8:1067–1071.

18. Gandhe RU, Bhave CP, Kakde AS, Sathe KA. Endovascular aspiration of clot in a 3-year-old child with embolic infarct of right middle cerebral artery. Saudi J Anaesth. 2018; 12:643–645.

19. Aburto-Murrieta Y, Méndez B, Marquez-Romero JM. Extended time window mechanical thrombectomy for pediatric acute ischemic stroke. J Cent Nerv Syst Dis. 2022; 14:11795735221098140.

20. Sarraj A, Hassan AE, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain MS, et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med. 2023; 388:1259–1271.

21. Yoshimura S, Sakai N, Yamagami H, Uchida K, Beppu M, Toyoda K, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022; 386:1303–1313.