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January 19, 2021; 96 (3) Article

Clinical Diffusion Mismatch to Select Pediatric Patients for Embolectomy 6 to 24 Hours After Stroke

An Analysis of the Save ChildS Study

Peter B. Sporns, Marios-Nikos Psychogios, Ronald Straeter, Uta Hanning, Jens Minnerup, René Chapot, View ORCID ProfileHans Henkes, Elina Henkes, Astrid Grams, Franziska Dorn, View ORCID ProfileOmid Nikoubashman, Martin Wiesmann, Georg Bier, Anushe Weber, Gabriel Broocks, View ORCID ProfileJens Fiehler, Alex Brehm, View ORCID ProfileDaniel Kaiser, Umut Yilmaz, View ORCID ProfileAndrea Morotti, Wolfgang Marik, View ORCID ProfileRichard Nolz, Ulf Jensen-Kondering, Michael Braun, Stefan Schob, Oliver Beuing, Friedrich Goetz, View ORCID ProfileJohannes Trenkler, Bernd Turowski, Markus Möhlenbruch, Christina Wendl, Peter Schramm, View ORCID ProfilePatricia L. Musolino, Sarah Lee, Marc Schlamann, Alexander Radbruch, André Karch, View ORCID ProfileNicole Rübsamen, Moritz Wildgruber, André Kemmling, the Save ChildS Investigators
First published November 3, 2020, DOI: https://doi.org/10.1212/WNL.0000000000011107
Peter B. Sporns
From the Department of Neuroradiology (P.B.S., M.-N.P., A.B.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., U.H., G.B., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Pediatrics (R.S.), and Neurology (J.M.), University Hospital of Muenster; Department of Neuroradiology (R.C.), Alfried-Krupp Hospital, Essen; Department of Neuroradiology (H.H., E.H.), Klinikum Stuttgart, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department for Diagnostic and Interventional Neuroradiology (F.D.), University of Munich (LMU), Campus Grosshadern; Department of Neuroradiology (O.N., M.W.), RWTH Aachen University; Diagnostic and Interventional Neuroradiology (G.B.), Eberhard Karls University Tuebingen; Department of Radiology and Neuroradiology (A.W.), University Hospital Knappschaftskrankenhaus Bochum Langendreer; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden7; Department of Neuroradiology (U.Y.), Saarland University Hospital, Homburg, Germany; ASST Valcamonica (A.M.), Ospedale di Esine, UOSD Neurologia, Esine, Italy; Division of Neuroradiology and Musculoskeletal Radiology (W.M.), Department of Biomedical Imaging and Image-Guided Therapy, and Department of Biomedical Imaging and Image-Guided Therapy (R.N.), Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Austria; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Kiel; Section of Neuroradiology (M.B.), University of Ulm, Guenzburg; Department for Neuroradiology (S.S.), University Hospital Leipzig; Department of Neuroradiology (O.B.), University Hospital of Magdeburg; Department of Diagnostic and Interventional Neuroradiology (F.G.), Hannover Medical School, Germany; Institute of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Institute of Neuroradiology (B.T.), University Hospital Duesseldorf; Department of Neuroradiology at Heidelberg University Hospital (M.M.); Department of Radiology (C.W.), University Hospital Regensburg; Department of Neuroradiology (P.S., A. Kemmling), University Hospital of Luebeck, Germany; Department of Neurology (P.L.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Child Neurology (S.L.), Department of Neurology, Stanford University, CA; Department of Neuroradiology (M.S.), University Hospital of Cologne; Department of Diagnostic and Interventional Radiology and Neuroradiology (A.R.), University Hospital Essen, University of Duisburg-Essen; Institute of Epidemiology and Social Medicine (A. Karch, N.R.), University of Muenster; and Department of Radiology, University of Munich (LMU) (M.W.), Campus Grosshadern, Germany.
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Marios-Nikos Psychogios
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Ronald Straeter
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Uta Hanning
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Jens Minnerup
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René Chapot
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Hans Henkes
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Elina Henkes
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Astrid Grams
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Franziska Dorn
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Omid Nikoubashman
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Martin Wiesmann
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Georg Bier
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Anushe Weber
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Gabriel Broocks
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Jens Fiehler
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Alex Brehm
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Daniel Kaiser
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Umut Yilmaz
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Andrea Morotti
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Wolfgang Marik
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Richard Nolz
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Ulf Jensen-Kondering
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Michael Braun
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Stefan Schob
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Oliver Beuing
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Friedrich Goetz
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Johannes Trenkler
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Bernd Turowski
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Markus Möhlenbruch
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Christina Wendl
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Peter Schramm
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Patricia L. Musolino
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Sarah Lee
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Marc Schlamann
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Alexander Radbruch
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André Karch
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Nicole Rübsamen
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Moritz Wildgruber
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André Kemmling
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Citation
Clinical Diffusion Mismatch to Select Pediatric Patients for Embolectomy 6 to 24 Hours After Stroke
An Analysis of the Save ChildS Study
Peter B. Sporns, Marios-Nikos Psychogios, Ronald Straeter, Uta Hanning, Jens Minnerup, René Chapot, Hans Henkes, Elina Henkes, Astrid Grams, Franziska Dorn, Omid Nikoubashman, Martin Wiesmann, Georg Bier, Anushe Weber, Gabriel Broocks, Jens Fiehler, Alex Brehm, Daniel Kaiser, Umut Yilmaz, Andrea Morotti, Wolfgang Marik, Richard Nolz, Ulf Jensen-Kondering, Michael Braun, Stefan Schob, Oliver Beuing, Friedrich Goetz, Johannes Trenkler, Bernd Turowski, Markus Möhlenbruch, Christina Wendl, Peter Schramm, Patricia L. Musolino, Sarah Lee, Marc Schlamann, Alexander Radbruch, André Karch, Nicole Rübsamen, Moritz Wildgruber, André Kemmling, the Save ChildS Investigators
Neurology Jan 2021, 96 (3) e343-e351; DOI: 10.1212/WNL.0000000000011107

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Abstract

Objective To determine whether thrombectomy is safe in children up to 24 hours after onset of symptoms when selected by mismatch between clinical deficit and infarct.

Methods A secondary analysis of the Save ChildS Study (January 2000–December 2018) was performed, including all pediatric patients (<18 years) diagnosed with arterial ischemic stroke who underwent endovascular recanalization at 27 European and United States stroke centers. Patients were included if they had a relevant mismatch between clinical deficit and infarct.

Results Twenty children with a median age of 10.5 (interquartile range [IQR] 7–14.6) years were included. Of those, 7 were male (35%), and median time from onset to thrombectomy was 9.8 (IQR 7.8–16.2) hours. Neurologic outcome improved from a median Pediatric NIH Stroke Scale score of 12.0 (IQR 8.8–20.3) at admission to 2.0 (IQR 1.2–6.8) at day 7. Median modified Rankin Scale (mRS) score was 1.0 (IQR 0–1.6) at 3 months and 0.0 (IQR 0–1.0) at 24 months. One patient developed transient peri-interventional vasospasm; no other complications were observed. A comparison of the mRS score to the mRS score in the DAWN and DEFUSE 3 trials revealed a higher proportion of good outcomes in the pediatric compared to the adult study population.

Conclusions Thrombectomy in pediatric ischemic stroke in an extended time window of up to 24 hours after onset of symptoms seems safe and neurologic outcomes are generally good if patients are selected by a mismatch between clinical deficit and infarct.

Classification of Evidence This study provides Class IV evidence that for children with acute ischemic stroke with a mismatch between clinical deficit and infarct size, thrombectomy is safe.

Glossary

AIS=
arterial ischemic stroke;
ASPECTS=
Alberta Stroke Program Early CT Score;
DAWN=
DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo;
DEFUSE 3=
Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke;
eTICI=
expanded Treatment in Cerebral Infarction;
IQR=
interquartile range;
LVO=
large vessel occlusion;
mRS=
modified Rankin Scale;
PedNIHSS=
Pediatric NIH Stroke Scale;
PSOM=
Pediatric Stroke Outcome Measure

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • ↵* These authors contributed equally to this work

  • Class of Evidence: NPub.org/coe

  • Received March 11, 2020.
  • Accepted in final form August 28, 2020.
  • © 2020 American Academy of Neurology
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