Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study

Peter B Sporns; Kartik Bhatia; Todd Abruzzo; Lisa Pabst; Stuart Fraser; Melissa G Chung; Warren Lo; Ahmed Othman; Sebastian Steinmetz; Ulf Jensen-Kondering; Stefan Schob; Daniel P O Kaiser; Wolfgang Marik; Christina Wendl; Ilka Kleffner; Hans Henkes; Hermann Kraehling; Thi Dan Linh Nguyen-Kim; René Chapot; Umut Yilmaz; Furene Wang; Muhammad Ubaid Hafeez; Flavio Requejo; Nicola Limbucci; Birgit Kauffmann; Markus Möhlenbruch; Omid Nikoubashman; Peter D Schellinger; Patricia Musolino; Ali Alawieh; Jenny Wilson; Dominik Grieb; Alexandra S Gersing; Thomas Liebig; Martin Olivieri; Jaroslava Paulasova Schwabova; Ales Tomek; Panagiotis Papanagiotou; Grégoire Boulouis; Olivier Naggara; Christine K Fox; Kirill Orlov; Alexandra Kuznetsova; Carmen Parra-Farinas; Prakash Muthusami; Robert W Regenhardt; Adam A Dmytriw; Tanja Burkard; Mesha Martinez; Daniel Brechbühl; Maja Steinlin; Lisa R Sun; Ameer E Hassan; André Kemmling; Sarah Lee; Heather J Fullerton; Jens Fiehler; Marios-Nikos Psychogios; Moritz Wildgruber

doi:10.1016/S2352-4642(24)00233-5

Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study

Lancet Child Adolesc Health. 2024 Oct 11:S2352-4642(24)00233-5. doi: 10.1016/S2352-4642(24)00233-5. Online ahead of print.

Authors

Peter B Sporns¹, Kartik Bhatia², Todd Abruzzo³, Lisa Pabst⁴, Stuart Fraser⁵, Melissa G Chung⁶, Warren Lo⁷, Ahmed Othman⁸, Sebastian Steinmetz⁸, Ulf Jensen-Kondering⁹, Stefan Schob¹⁰, Daniel P O Kaiser¹¹, Wolfgang Marik¹², Christina Wendl¹³, Ilka Kleffner¹⁴, Hans Henkes¹⁵, Hermann Kraehling¹⁶, Thi Dan Linh Nguyen-Kim¹⁷, René Chapot¹⁸, Umut Yilmaz¹⁹, Furene Wang²⁰, Muhammad Ubaid Hafeez²¹, Flavio Requejo²², Nicola Limbucci²³, Birgit Kauffmann²⁴, Markus Möhlenbruch²⁵, Omid Nikoubashman²⁶, Peter D Schellinger²⁷, Patricia Musolino²⁸, Ali Alawieh²⁹, Jenny Wilson³⁰, Dominik Grieb³¹, Alexandra S Gersing³², Thomas Liebig³², Martin Olivieri³³, Jaroslava Paulasova Schwabova³⁴, Ales Tomek³⁵, Panagiotis Papanagiotou³⁶, Grégoire Boulouis³⁷, Olivier Naggara³⁸, Christine K Fox³⁹, Kirill Orlov⁴⁰, Alexandra Kuznetsova⁴¹, Carmen Parra-Farinas⁴², Prakash Muthusami⁴², Robert W Regenhardt⁴³, Adam A Dmytriw⁴⁴, Tanja Burkard⁴⁵, Mesha Martinez⁴⁶, Daniel Brechbühl⁴⁷, Maja Steinlin⁴⁸, Lisa R Sun⁴⁹, Ameer E Hassan⁵⁰, André Kemmling⁵¹, Sarah Lee⁵², Heather J Fullerton³⁹, Jens Fiehler⁵³, Marios-Nikos Psychogios⁵⁴, Moritz Wildgruber⁴⁵

Affiliations

¹ Department of Neuroradiology, University Hospital Basel, Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Radiology and Neuroradiology, Stadtspital Zürich, Zürich, Switzerland. Electronic address: [email protected].
² Department of Medical Imaging, Children's Hospital at Westmead, Sydney, NSW, Australia; Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
³ Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA; Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA.
⁴ Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
⁵ Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, USA.
⁶ Division of Critical Care Medicine and Division of Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA.
⁷ Department of Pediatrics and Department of Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA.
⁸ Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
⁹ Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Kiel, Germany; Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany.
¹⁰ Department of Radiology and Neuroradiology, University Hospital Halle, Halle, Germany.
¹¹ Institute of Neuroradiology, Medical Faculty and University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany.
¹² Department of Neuroradiology, Medical University of Vienna, Vienna, Austria.
¹³ Institute of Radiology, University Hospital Regensburg, Regensburg, Germany.
¹⁴ Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany.
¹⁵ Neuroradiological Clinic, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany.
¹⁶ Clinic for Radiology, Department for Interventional Neuroradiology, University of Münster, Münster, Germany.
¹⁷ Department of Radiology and Neuroradiology, Stadtspital Zürich, Zürich, Switzerland.
¹⁸ Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Essen, Germany.
¹⁹ Department of Neuroradiology, Saarland University Hospital, Homburg, Germany.
²⁰ Department of Paediatrics, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore.
²¹ Department of Neurology, Baylor College of Medicine, Houston, TX, USA.
²² Department of Neuroradiology, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina.
²³ Department of Interventional Neuroradiology, Careggi University Hospital, Florence, Italy.
²⁴ Department of Pediatrics and Adolescent Medicine, Eltern-Kind-Zentrum Prof Hess, Klinikum Bremen Mitte, Bremen, Germany.
²⁵ Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.
²⁶ Department of Neuroradiology, Aachen University, Aachen, Germany.
²⁷ Department of Neurology and Neurogeriatrics, University Clinic of the Ruhr-Universität Bochum, Minden, Germany.
²⁸ Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
²⁹ Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
³⁰ Division of Pediatric Neurology, Oregon Health & Science University, Portland, OR, USA.
³¹ Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany; Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany.
³² Department of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany.
³³ Pediatric Thrombosis and Hemostasis Unit, Dr von Hauner Children's Hospital, LMU Munich, Munich, Germany.
³⁴ Department of Paediatric Neurology, Comprehensive Stroke Center, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic; Department of Neurology, Comprehensive Stroke Center, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
³⁵ Department of Neurology, Comprehensive Stroke Center, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
³⁶ Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Bremen, Germany; First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Areteion Hospital, Athens, Greece.
³⁷ Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France; French Center for Pediatric Stroke, Paris, France.
³⁸ French Center for Pediatric Stroke, Paris, France; Department of Pediatric Radiology, Faculté de Médecine, Necker Children's Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
³⁹ Department of Neurology and Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
⁴⁰ Research Center of Endovascular Neurosurgery, Federal Center of Brain Research and Neuro Technologies of FMBA, Moscow, Russia; Morozov Moscow Children Clinical Hospital, Moscow, Russia.
⁴¹ Morozov Moscow Children Clinical Hospital, Moscow, Russia; Division of Neuroradiology and Division of Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
⁴² Division of Neuroradiology and Division of Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
⁴³ Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁴⁴ Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St Michael's Hospital, University of Toronto, ON, Canada.
⁴⁵ Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany.
⁴⁶ University Hospital, LMU Munich, Germany; Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
⁴⁷ Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
⁴⁸ Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
⁴⁹ Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
⁵⁰ Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA.
⁵¹ Department of Neuroradiology, University of Marburg, Marburg, Germany.
⁵² Division of Child Neurology, Department of Neurology, Stanford University, Stanford, CA, USA.
⁵³ Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁵⁴ Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.

PMID: 39401507
DOI: 10.1016/S2352-4642(24)00233-5

Abstract

Background: Emerging evidence suggests that endovascular thrombectomy is beneficial for treatment of childhood stroke, but the safety and effectiveness of endovascular thrombectomy has not been compared with best medical treatment. We aimed to prospectively analyse functional outcomes of endovascular thrombectomy versus best medical treatment in children with intracranial arterial occlusion stroke.

Methods: In this prospective registry study, 45 centres in 12 countries across Asia and Australia, Europe, North America, and South America reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischaemic stroke caused by a large-vessel or medium-vessel occlusion who received either endovascular thrombectomy plus best medical practice or best medical treatment alone. Intravenous thrombolysis was considered part of best medical treatment and therefore permitted in both groups. The primary outcome was the difference in median modified Rankin Scale (mRS) score between baseline (pre-stroke) and 90 days (±10 days) post-stroke, assessed by the Wilcoxon rank test (α=0·05). Efficacy outcomes in the endovascular thrombectomy and best medical treatment groups were compared in sensitivity analyses using propensity score matching. The Save ChildS Pro study is registered at the German Clinical Trials Registry, DRKS00018960.

Findings: Between Jan 1, 2020, and Aug 31, 2023, of the 241 patients in the Save ChildS Pro registry, 208 were included in the analysis (115 [55%] boys and 93 [45%] girls). 117 patients underwent endovascular thrombectomy (median age 11 years [IQR 6-14]), and 91 patients received best medical treatment (6 years [3-12]; p<0·0001). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score on admission was 14 (IQR 10-19) in the endovascular thrombectomy group and 9 (5-13) in the best medical treatment group (p<0·0001). Both treatment groups had a median pre-stroke mRS score of 0 (IQR 0-0) at baseline. The change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·020). One (1%) patient developed a symptomatic intracranial haemorrhage (this patient was in the endovascular thrombectomy group). Six (5%) patients in the endovascular thrombectomy group and four (5%) patients in the best medical treatment group had died by day 90 (p=0·89). After propensity score matching for age, sex, and PedNIHSS score at hospital admission (n=79 from each group), the change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·029). Regarding the primary outcome for patients with suspected focal cerebral arteriopathy, endovascular thrombectomy (n=18) and best medical treatment (n=33) showed no difference in 90-day median mRS scores (2 [IQR 1-3] vs 2 [1-4]; p=0·074).

Interpretation: Clinical centres tended to select children with more severe strokes (higher PedNIHSS score) for endovascular thrombectomy. Nevertheless, endovascular thrombectomy was associated with improved functional outcomes in paediatric patients with large-vessel or medium-vessel occlusions compared with best medical treatment. Future studies need to investigate whether the positive effect of endovascular thrombectomy is confined to older and more severely affected children.

Funding: None.