Department of Public Health, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Neurology & Public Health, 5925Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Int J Stroke. 2021 Feb;16(2):172-183. doi: 10.1177/1747493020904915. Epub 2020 Feb 2.
Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population.
We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations.
We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003-2014) in pediatric (1-21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations.
In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003-2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups ( < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50-147.29, = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92-40.76, = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16-49.31, = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group.
We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.
小儿脑卒中是一种使人虚弱的疾病。有几个使儿童易患这种危及生命的疾病的危险因素。尽管发表的文献估计小儿脑卒中的发病率相对较高，但关于静脉组织型纤溶酶原激活剂和血管内血栓切除术的治疗指南仍然存在争议。缺乏大型基于人群的研究和临床试验来评估这些治疗方法在这一独特人群中的疗效和安全性结局。
我们旨在确定小儿脑卒中住院患者的危险因素、静脉组织型纤溶酶原激活剂和血管内血栓切除术的同时使用情况以及相关结局。
我们使用 ICD-9-CM 代码对 2003-2014 年全国住院患者样本（NIS）中 1-21 岁急性缺血性脑卒中住院患者进行回顾性分析。多变量调查逻辑回归模型进行了加权处理，以考虑抽样策略、评估出血性转化的预测因素以及小儿脑卒中住院患者的治疗结局（死亡率、发病率和出院处置）。
在这项分析中，2003-2014 年间有 9109 名 1-21 岁的儿童因急性缺血性脑卒中住院。在这 9109 名患者中，有 119 名（1.30%）单独接受血管内血栓切除术，256 名（2.82%）接受静脉重组组织型纤溶酶原激活剂治疗，69 名（0.75%）接受血管内血栓切除术和静脉重组组织型纤溶酶原激活剂治疗。我们发现，小儿急性缺血性脑卒中患者中普遍存在癫痫（19.59%）、房间隔缺损（11.76%）、镰状细胞病（8.63%）和烟雾病（5.41%）等疾病。未调整分析显示，联合使用血管内血栓切除术和静脉重组组织型纤溶酶原激活剂的患者全因院内死亡率普遍较高，血管内血栓切除术组的出血性转化和发病率较高，与其他组相比（ < 0.0001）。多变量调整分析显示，使用血管内血栓切除术（比值比：19.19；95%置信区间：2.50-147.29， = 0.005）、静脉重组组织型纤溶酶原激活剂（比值比：8.85；95%置信区间：1.92-40.76， = 0.005）和两者（血管内血栓切除术和静脉重组组织型纤溶酶原激活剂）的患者与未治疗组相比，出血性转化的可能性更高（比值比：7.55；95%置信区间：1.16-49.31， = 0.035）。
我们发现了与小儿脑卒中相关的各种危险因素。早期识别有助于制定预防策略并影响小儿脑卒中的发生率。我们的研究结果表明，静脉组织型纤溶酶原激活剂和血管内血栓切除术的使用增加了死亡率和出血性转化的风险，但我们建议进行更多的临床研究，以评估基于风险效益比的静脉组织型纤溶酶原激活剂和血管内血栓切除术的适宜患者。
