Neurointervention.  2014 Sep;9(2):94-100. 10.5469/neuroint.2014.9.2.94.

Successful Mechanical Thrombectomy in a 2-Year-Old Male Through a 4-French Guide Catheter

• Stidd DA
• Lopes DK

• KMID: 1910765
• DOI: http://doi.org/10.5469/neuroint.2014.9.2.94

Abstract

A 2-year-old boy with hypoplastic left heart syndrome that required multiple cardiovascular surgeries and a heterozygous prothrombin G20210A mutation with resulting thrombophilia maintained on warfarin presented with acute right middle cerebral artery (MCA) infarction manifesting as a left hemiplegia. An MRI revealed a complete occlusion of the right M1 segment with an area of restricted diffusion in the right basal ganglia representing only a small area of acute infarction. Patchy areas of subacute infarction were also present in the right MCA territory. He underwent endovascular mechanical thrombectomy with a stent retriever. This is an account of a successful mechanical thrombectomy performed in the youngest patient reported in the English literature to date.

Keyword

Acute ischemic stroke; Coagulopathy; Mechanical thrombectomy; Pediatric acute ischemic stroke; Stent retriever

MeSH Terms

Basal Ganglia
Catheters*
Child, Preschool*
Diffusion
Hemiplegia
Humans
Hypoplastic Left Heart Syndrome
Infarction
Magnetic Resonance Imaging
Male
Middle Cerebral Artery
Prothrombin
Stents
Thrombectomy*
Thrombophilia
Warfarin
Prothrombin
Warfarin

Figure

• 

  Fig. 1 A. Maximum intensity projection from a time-of-flight MRA demonstrating an occlusion of the proximal right M1 segment (arrowhead). B. Diffusion weighted MRI demonstrating restricted diffusion within the right lentiform nucleus and posterior limb of the internal capsule (arrow).

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  Fig. 2 A. Anterior-posterior (AP) catheter angiogram of a right internal carotid injection demonstrating occlusion of the proximal M1 segment (arrowhead). B. AP angiogram of an injection through a microcatheter passed through the M1 segment thrombus demonstrating distal opacification of the right MCA territory. C. A 3 × 20 mm stent retriever (arrows) is deployed through the M1 thrombus. The 3 × 20 mm stent retriever has 2 radiopaque distal markers. The distal radiopaque marker of the microcatheter is visible proximal to the stent (bold arrow) and the 4F guide catheter is just visible (arrow outline).

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  Fig. 3 After the first pass of the 3 × 20 mm stent retriever, thrombus (arrowhead) remained in the right M1 segment (A) and a thrombus fragment (arrowhead) migrated into the distal right ACA distribution shown on the lateral angiogram (B). A larger 4 × 20 mm stent retriever (arrows) was deployed through the thrombus in the M1 segment (C). The 4 × 20 mm stent retriever has 3 distal markers and the distal marker of the microcatheter is noted proximal to the stent (bold arrow). The 4F guide catheter is visible (arrow outline).

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  Fig. 4 A. An anterior-posterior angiogram showing robust distal opacification of the right MCA distribution after a successful thrombectomy from the M1 segment using a third pass of a stent retriever. Prior to withdrawal of the last stent retriever, the microcatheter was carefully withdrawn and careful aspiration was applied to the 4F guide catheter in the ICA while the stent was withdrawn. B. The thrombus in the distal ACA distribution (arrowhead) remained after the clot was removed from the M1 segment. C. A 4 × 20 mm stent retriever (arrows) is deployed through the thrombus in the right ACA. The distal marker of the microcatheter is proximal to the stent (bold arrow).

• 

  Fig. 5 Anterior-posterior and lateral cerebral arterial phase angiograms after successful mechanical thrombectomies resulting in a partial reperfusion in the right MCA territory and complete reperfusion in right ACA territory.

Reference

1. Hu YC, Chugh C, Jeevan D, Gillick JL, Marks S, Stiefel MF. Modern endovascular treatments of occlusive pediatric acute ischemic strokes: case series and review of the literature. Childs Nerv Syst. 2014; 30:937–943. PMID: 24212331.

2. Arnold M, Steinlin M, Baumann A, Nedeltchev K, Remonda L, Moser SJ, et al. Thrombolysis in childhood stroke: report of 2 cases and review of the literature. Stroke. 2009; 40:801–807. PMID: 19118242.

3. Ellis MJ, Amlie-Lefond C, Orbach DB. Endovascular therapy in children with acute ischemic stroke: review and recommendations. Neurology. 2012; 79(13 Suppl 1):S158–S164. PMID: 23008391.

4. Di Carlo A. Human and economic burden of stroke. Age Ageing. 2009; 38:4–5. PMID: 19141505.

5. Srinivasan J, Miller SP, Phan TG, Mackay MT. Delayed recognition of initial stroke in children: need for increased awareness. Pediatrics. 2009; 124:e227–e234. PMID: 19620205.

6. Monagle P, Chalmers E, Chan A, DeVeber G, Kirkham F, Massicotte P, et al. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl):887S–968S. PMID: 18574281.

7. Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008; 39:2644–2691. PMID: 18635845.

8. Dubedout S, Cognard C, Cances C, Albucher JF, Cheuret E. Successful clinical treatment of child stroke using mechanical embolectomy. Pediatr Neurol. 2013; 49:379–382. PMID: 24139537.

9. Kuhle S, Male C, Mitchell L. Developmental hemostasis: pro- and anticoagulant systems during childhood. Semin Thromb Hemost. 2003; 29:329–338. PMID: 14517745.

10. Fargen KM, Meyers PM, Khatri P, Mocco J. Improvements in recanalization with modern stroke therapy: a review of prospective ischemic stroke trials during the last two decades. J Neurointerv Surg. 2013; 5:506–511. PMID: 23042748.

11. Zaidat OO, Tolbert M, Smith TP, Alexander MJ. Primary endovascular therapy with clot retrieval and balloon angioplasty for acute basilar artery occlusion. Pediatr Neurosurg. 2005; 41:323–327. PMID: 16293952.

12. Tsivgoulis G, Horton JA, Ness JM, Patterson D, Brethour M, Abanses JC, et al. Intravenous thrombolysis followed by intraarterial thrombolysis and mechanical thrombectomy for the treatment of pediatric ischemic stroke. J Neurol Sci. 2008; 275:151–153. PMID: 18722630.

13. Felker MV, Zimmer JA, Golomb MR. Failure of a clot retrieval device in an adolescent stroke patient. Pediatr Neurol. 2010; 43:435–438. PMID: 21093737.

14. Grunwald IQ, Walter S, Shamdeen MG, Dautermann A, Roth C, Haass A, et al. New mechanical recanalization devices - the future in pediatric stroke treatment? J Invasive Cardiol. 2010; 22:63–66. PMID: 20124590.

15. Taneja SR, Hanna I, Holdgate A, Wenderoth J, Cordato DJ. Basilar artery occlusion in a 14-year old female successfully treated with acute intravascular intervention: case report and review of the literature. J Paediatr Child Health. 2011; 47:408–414. PMID: 21276116.

16. Fink J, Sonnenborg L, Larsen LL, Born AP, Holtmannspotter M, Kondziella D. Basilar Artery Thrombosis in a Child Treated With Intravenous Tissue Plasminogen Activator and Endovascular Mechanical Thrombectomy. J Child Neurol. 2013; 28:1521–1526. PMID: 23034976.

17. Xavier A, Kansara A, Majjhoo AQ, Norris G. CT perfusion guided delayed recanalization with favorable outcome in pediatric stroke. J Neurointerv Surg. 2012; 4:e33. PMID: 22146572.

18. Tatum J, Farid H, Cooke D, Fullerton H, Smith W, Higashida R, et al. Mechanical embolectomy for treatment of large vessel acute ischemic stroke in children. J Neurointerv Surg. 2013; 5:128–134. PMID: 22307540.

19. Sainz de la Maza S, De Felipe A, Matute MC, Fandino E, Mendez JC, Morillo P, et al. Acute ischemic stroke in a 12-year-old successfully treated with mechanical thrombectomy. J Child Neurol. 2014; 29:269–273. PMID: 24272519.

20. Rhee E, Hurst R, Pukenas B, Ichord R, Cahill AM, Rossano J, et al. Mechanical embolectomy for ischemic stroke in a pediatric ventricular assist device patient. Pediatr Transplant. 2014; 18:E88–E92. PMID: 24646292.

21. Fields JD, Lindsay K, Liu KC, Nesbit GM, Lutsep HL. Mechanical thrombectomy for the treatment of acute ischemic stroke. Expert Rev Cardiovasc Ther. 2010; 8:581–592. PMID: 20397831.