Bhatia Kartik, Kortman Hans, Blair Christopher, Parker Geoffrey, Brunacci David, Ang Timothy, Worthington John, Muthusami Prakash, Shoirah Hazem, Mocco J, Krings Timo
1Department of Neuroradiology, Toronto Western Hospital.
Departments of2Interventional Neuroradiology and.
J Neurosurg Pediatr. 2019 Aug 9;24(5):558-571. doi: 10.3171/2019.5.PEDS19126. Print 2019 Nov 1.
The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.
Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).
The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.
Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.
尽管有大量证据表明机械取栓术对成人有益，但该技术在儿童急性缺血性卒中中的作用仍不明确。现有文献包括近期几项小型单臂队列研究，以及此前多项小型病例系列研究和病例报告。自2015年成人机械取栓术阳性试验发表后，儿科病例的报道显著增加。近期美国心脏协会/美国卒中协会关于此问题的科学声明主要依据2015年前的病例报告，发现了几个知识空白，包括儿童多大年龄可接受取栓术。有必要进行重复的系统评价和荟萃分析，以帮助指导治疗决策并填补知识空白。
作者按照PRISMA-IPD指南，对1999年至2019年4月的文献进行了系统评价，并进行了个体患者数据荟萃分析，由2名独立评审员参与。还纳入了作者所在中心的另外3例青少年男性病例。主要结局是18岁以下急性缺血性卒中患者接受机械取栓术后良好的长期（末次随访时改良Rankin量表评分0 - 2分）和短期（取栓术后24小时内美国国立卫生研究院卒中量表评分降低≥8分或美国国立卫生研究院卒中量表评分0 - 1分）神经功能结局发生率。次要结局是血管造影成功再通率（脑梗死溶栓分级量表评分2b/3级）。
作者的综述纳入了110例儿科患者的113例机械取栓术病例。虽然并非所有患者都有完整的随访数据，但96例中有87例（90.6%）有良好的长期神经功能结局（改良Rankin量表评分0 - 2分），79例中有55例（69.6%）有良好的短期神经功能结局，98例中有86例（87.8%）血管造影成功再通（脑梗死溶栓分级量表评分2b/3级）。2例患者死亡，1例患者发生有症状颅内出血。在5岁以下儿童中确定了16例已发表的取栓病例。
对于1 - 18岁因大血管闭塞（颈内动脉末端、大脑中动脉M1段、基底动脉）导致的急性缺血性卒中患者，可考虑行机械取栓术（C级证据；IIb类推荐）。现有证据基础可能受到选择偏倚和发表偏倚的影响。建议下一步进行前瞻性跨国注册研究。
