Large vessel occlusion stroke is associated with poor prognosis in children

1. Pediatric patients presenting with large vessel occlusion stroke have a high probability of developing disabling neurological outcomes or death.

2. Most children with large vessel occlusion stroke present to medical attention within the window of opportunity for thrombectomy treatment.

Level of Evidence: 2 (Good)

Study Rundown: Large vessel occlusion (LVO) stroke is well described in adults, and is known to be associated with worse outcomes than other non-LVO arterial ischemic stroke types. However, the natural history and prognosis of LVO stroke, amongst other vascular ischemic events, is poorly understood in the pediatric population. The present study by Bhatia et al sought to characterize the incidence of LVO stroke amongst children in Australia, as well as the associated morbidity and opportunities for intervention. 161 pediatric patients presenting with a stroke between 2010 and 2019 were included in this study over the course of 166 hospital admissions. LVO was present in 39 of these hospitalizations (23.5%), and 13 of these patients (33.3%) underwent therapeutic thrombectomy. The remaining 26 patients received conservative therapy. Patients with LVO stroke were older at baseline than patients with non-LVO stroke. The mean incidence of pediatric acute ischemic stroke was 1.02 per 100,000 person-years and that of pediatric LVO stroke was 0.24 per 100,000 person-years. 73% of patients who had an LVO stroke and no thrombectomy had a functional pediatric mRS score between 3 and 6 (representing disability) at 3 months, while only 50% of those who had undergone thrombectomy were considered to have a disability at 3 months. 35 of the 39 patients with LVO had presented to hospital within 24 hours of the index event. Bhatia et al concluded that LVO stroke is associated with a worse prognosis than non-LVO stroke in children, and that those treated with thrombectomy tended to fare better in terms of disability status even months after the index event. Some strengths of this research include the strong basis for the study (i.e., the extent of available literature about LVO stroke amongst adults) and the long follow up period. However, methodological weaknesses include that the sample size of the study is relatively small, owing to the thankfully low incidence of strokes in children. Additionally, the retrospective nature of this work made it impossible to control for confounding bias. Future research should focus on the potential for therapeutics identified in this study, including eligibility and access to thrombectomy in patients presenting with LVO stroke.

Click here to read this study in JAMA Neurology

Relevant Reading: Predicting recovery and outcome after pediatric stroke: results from the International Pediatric Stroke study

In-Depth [retrospective cohort]: A multicenter, retrospective cohort study was conducted. Patients were eligible for inclusion if they were aged 1 month to 17 years and presented with an acute ischemic stroke between January 2010 and December 2019, as defined by diagnostic codes assigned by a pediatric neurologist. LVO was defined as the acute occlusion of a number of intracerebral arteries as demonstrated on imaging. Imaging characteristics were also used to define the timeline of the vascular event as being either acute or chronic. Population level data to define the incidence rate of stroke was derived from publicly-available national databases. The primary outcome was functional status at 3 months after the index event as measured by the pediatric mRS score. In this system, scores of 1-2 represent no disability, 3-6 represents increasing levels of disability and a score of 7 represents death. The mean incidence of pediatric acute ischemic stroke was 1.02 per 100,000 person-years with a standard deviation of 0.18; the mean incidence of pediatric LVO stroke was 0.24 per 100,000 person-years with a standard deviation of 0.15.  Amongst the LVO stroke patients who had no thrombectomy, 19 of 26 (73.1%) had a disability at 3 months; amongst those who had no thrombectomy, 6 of 12 (50%) had a disability at 3 months. Finally, 52 of 126 (41.2%) of patients who had a non-LVO stroke were found to have a disability at 3 months. The most likely site of LVO was within the anterior circulation in 75% of LVO strokes. The odds ratio for poor outcome in patients who had not had thrombectomy compared to those who did following LVO stroke was 3.75 (95% confidence interval 1.05-13.45) at 3 months and 6.07 (1.55-3.73) at the time of the final assessment. This relationship was more pronounced in the patients who had had an anterior cerebral artery occlusion.

Image: PD

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