Childs Nerv Syst
DOI 10.1007/s00381-012-1869-7

BRIEF COMMUNICATION

A successful treatment of arterial ischemic stroke with stent
insertion in a child with congenital heart disease
Hee Joon Yu & I-Seok Kang & Munhyang Lee &
Keon-Ha Kim & Jeehun Lee

Received: 17 June 2012 / Accepted: 17 July 2012
# Springer-Verlag 2012

Abstract
Introduction Diagnosis of arterial ischemic stroke in pediatric patients is often delayed due to the uncertainty and
variability of clinical symptoms. Early diagnosis of arterial
ischemic stroke can bring a favorable prognosis with prompt
thrombolytic therapy or stent insertion, via transfemoral
cerebral arteriogram. Acute thrombolytic therapy is rarely
attempted in children because of the delayed diagnosis.
Patient and method We report a case of a 4-year-old girl
with complex heart disease who was presented with arterial
ischemic stroke at the right distal internal carotid artery and
successfully treated by stent insertion in which repeated
thrombolysis or ballooning had failed.
Result Left hemiparesis was nearly recovered 6 days after
the stent insertion. The mean flow velocity of the right
middle cerebral artery has slightly improved compared to
that of the initial study. She has been followed-up for 6
months in the outpatient clinic without neurologic sequelae.
Conclusion This case suggests that intracranial stent insertion
may be a safe and an effective modality in young children,
when the thrombolytic therapy or ballooning is inapplicable.
Additionally, transcranial Doppler ultrasonography is useful

H. J. Yu : I.-S. Kang : M. Lee : J. Lee (*)
Department of Pediatrics,
Samsung Medical Center,
Sungkyunkwan University School of Medicine,
81, Irwon-Ro, Gangnam-Gu,
Seoul 135-710, Korea
e-mail: jhlee0101@skku.edu
K.-H. Kim
Department of Radiology,
Samsung Medical Center,
Sungkyunkwan University School of Medicine,
81, Irwon-Ro, Gangnam-Gu,
Seoul 135-710, Korea
e-mail: somatom@skku.edu

to monitor the cerebral blood flow after stent insertion in
children.
Keywords Arterial ischemic stroke . Transfemoral cerebral
arteriogram . Stent insertion . Complex heart disease .
Children

Introduction
An arterial ischemic stroke (AIS) occurs when arterial blood
flow to the brain is blocked by the narrowing of the artery or
when a blood clot in the artery blocks the supply of blood to
a part of the brain. The incidence of AIS in pediatric patients
is 2.6 in every 100,000 per year [1]. The common conditions
prone to pediatric AIS are cerebral arteriopathies, congenital
or acquired heart diseases, and sickle cell diseases [8].
Patients with AIS are usually accompanied with focal weakness, seizure, headache, hemiparesis, localized numbness or
tingling, alerted mental status, vision change, and ataxia [8].
In adults, the recombinant tissue plasminogen activator
has been proven to be a safe and an effective treatment for
AIS when administered 4.5 hours from the onset of the
symptoms [4]. Additionally, mechanical devices, such as
arterial stent, have evolved to improve the recanalization
rate. However, pediatric stroke is often under-recognized
and delayed in the diagnosis because of nonspecific presenting symptoms, which imposes many differential diagnoses
[5]. For those reasons, it is hard to use recombinant tissue
plasminogen activator or to apply stent-assisted mechanical
recanalization in pediatric AIS patients. Although excellent
results on the use of mechanical devices have been reported
in adult AIS, only one pediatric case with intracranial carotid artery dissection treated by stent insertion has been reported
in 2010 [7]. We describe a case of AIS, associated with
congenital heart disease, in a 4-year-old girl that was successfully treated with arterial stent insertion.

Childs Nerv Syst

Case report
A 4-year-old girl was admitted with complaint of worsening
fatigue and dyspnea on exertion, which began 2 months
ago. She was diagnosed with complete atrioventricular
septal defect and coarctation of aorta. She had undergone four operations; coarctoplasty, pulmonary artery
banding, total correction of complete atrioventricular septal
defect, aortopexy, and mitral valve and tricuspid valve
repair.
On admission, the echocardiography revealed aggravation of mitral valve regurgitation, along with hypoplasia and
stenosis of the left pulmonary artery. For that reason, she
underwent mitral valve replacement and left pulmonary
artery angioplasty. On the 13th day after the operation, she
had cardiectomy for constrictive pericarditis, which was
diagnosed by the presence of echogenic materials in the
pericardial space on a follow-up echocardiography.
Five days after the cardiectomy, persistent presence of
echogenic materials in the pericardium was noted on echocardiography. On the evening of the same day, she was
abruptly presented with left hemiparesis and left facial palsy.
Fig. 1 Brain computed
tomography shows a high
attenuated focal lesion at the
proximal portion of the right
middle cerebral artery on precontrast image (a). Transfemoral
cerebroarteriography reveals
narrowing and total occlusion at
the right internal carotid artery
angiography (anterior-posterior
view (b), lateral view (c)).
Left internal carotid artery
angiography shows normal
lumen (d)

She was alert, and the neurologic examination revealed
central-type left facial palsy, left hemiparesis (motor grade
2), positive Babinski sign, and positive ankle clonus on the
left side. The National Institutes of Health Stroke Scale was
ten. Computed tomography (CT) showed a highly attenuated
focal lesion at the bifurcated portion of the right internal
carotid artery (ICA) on the precontrast image and discontinuity of the right ICA on the postcontrast image (Fig. 1).
With that result, focal embolus in the right distal ICA was
suspected. Emergency transfemoral cerebral angiography
was tried in 90 min after the onset of the symptoms. A Tshaped total occlusion, at the right distal ICA, was observed
on transfemoral cerebral angiography (Fig. 1). It was
difficult to use a fibrinolytic agent, such as urokinase,
because she has had a mitral valve replacement 18 days
ago. We tried mechanical thrombolysis with ballooning.
Despite repetitive trials, the occlusion persisted when the
balloon deflated (Fig. 2). Thereafter, the stent (Enterprise
4.5×28 mm, Cordis Neurovascular, Inc., Miami, FL, USA)
was inserted, and recanalization of the middle cerebral
artery (MCA) was observed 4 hours after the onset of the
symptoms (Fig. 3).

Childs Nerv Syst
Fig. 2 Mechanical
thrombolysis with ballooning
is tried. Despite repetitive
trials, the occlusion persisted
(a and b). The inserted stent
is delineated (c)

After the stent insertion, we administered heparin,
aspirin, and clopidogrel to prevent thrombosis. The flow of
MCA was monitored via transcranial Doppler ultrasonography. During the first monitoring after the stent insertion, the
flow rate of the right MCA was faster than the left, reflecting
relative narrowing. For 14 days of monitoring, the flow rate
Fig. 3 Recanalization of the
middle cerebral artery is seen
after stent insertion

was well maintained without abrupt change (Fig. 4). Left
hemiparesis was nearly recovered 6 days after the stent
insertion. Movement of the left arm was somewhat slower,
but the motor power was normal, and the range of motion
was not limited. On the eighth day after stent insertion,
transient paresthesia and motor weakness in the left leg

Childs Nerv Syst

Fig. 4 This graph shows mean flow velocities of the right middle
cerebral artery (MCA), as measured by transcranial Doppler study after
stent insertion. Immediately after the stent insertion, highly increased
flow velocities were recorded from the right middle cerebral artery, and
mildly increased flow velocities were recorded from the left middle

cerebral artery, with the mean velocity at 112 cm/sec. The mean flow
velocity of the right middle cerebral artery decreased and stabilized,
and that of the left middle cerebral artery returned to normal (normal
mean flow velocity of middle cerebral artery, 94±10 cm/sec)

occurred and spontaneously recovered within 24 hours. The
mean flow velocity of the right MCA has slightly improved
compared to that of the previous day. The blood flow at the
proximal and distal MCA was well maintained on the brain
CT, examined at day 8, the evening after stent insertion. She
was taking aspirin and warfarin at discharge. She has been
followed-up for 6 months in the outpatient clinic without
neurologic sequelae.

This case was diagnosed immediately after the symptom
onset, and the thrombolytic therapy could be applied. However, it had not been considered because, recently, she had
undergone mitral valve replacement. Thus, we tried mechanical thrombolysis instead of applying a thrombolytic agent.
A thrombolytic agent, such as recombinant tissue plasminogen activator, has a narrow treatment time window of
4.5 hours from the onset of stroke. Delayed administration
of recombinant tissue plasminogen activator, over the acceptable time window, can increase the risk of intracranial hemorrhage [4].
As on alternative treatment method, a mechanical device
for revascularization was developed, and many clinical trials
using a mechanical device in adult patients are in progress.
The recanalization rate, using a mechanical device, is higher
than the rate of using a thrombolytic agent alone [12]. The
patient in this study was treated with the Enterprise stent,
which is a self-expanding stent and is placed by a catheterbased delivery system. A stent can move emboli or thrombi
toward the edges of the vessel lumen to rebuild luminal
patency and restore the blood flow. The device has been
shown to provide excellent navigability and ease of deployment [9]. Stent insertion requires anticoagulation, following
the procedure, which may increase the possibility of intracranial hemorrhage [14]. It was reported that revascularization was achieved in 100 % of patients using the Enterprise
stent, and symptomatic intracranial hemorrhage occurred in
two patients (10 %) [9]. The rate of intracranial hemorrhage
has been reported in 9–10 % of the patients who underwent
intracranial stent insertion [9]. We also paid great attention
to subsequent hemorrhage, monitoring the bleeding tendency
and patient’s neurologic status, and in our case, no clinically
significant hemorrhagic complications occurred. In addition,
the stent-associated thrombosis and restenosis may occur.

Discussion
This is a case of AIS associated with congenital heart
disease, which was detected immediately, and had been
successfully treated with arterial stent insertion after an
unsuccessful mechanical thrombolysis.
The primary management of AIS in adults is the treatment with antithrombotic agents, such as aspirin or heparin.
If the AIS is found in 4.5 hours, it is useful to use a
thrombolytic agent or to adopt stent-associated revascularization [6]. The treatment of childhood AIS is different from
that of adulthood. Many cases of childhood AIS are delayed
in diagnosis and not eligible to treat with thrombolytic
agents [4]. It was reported that in pediatric patients, the rate
of episodes mimicking a stroke was slightly higher than in
adults [13]. Conditions, which mimic a stroke includes
migraine, epilepsy, postictal paralysis, tumor, acute disseminated encephalomyelitis, reversible posterior leukoencephalopathy syndrome, acute postinfectious cerebellitis,
metabolic stroke, idiopathic intracranial hypertension, empyema, and intracranial abscess [13]. For that reason, diagnosis on children with AIS is delayed, and there is less
opportunity to try thrombolysis. Additionally, there has been
no report about stent insertion in childhood AIS.

Childs Nerv Syst

Fargen et al. reported long-term results of Enterprise stent,
and angiographic in-stent stenosis was seen in 3.4 % and
thromboembolic events occurred in 4.4 % [3]. In adult
patients, stenting is a hopeful option that appears to yield
higher recanalization rates and allows a broader treatment
window [2]. According to the result of this study, stent
implantation in children appears to be a safe and an optional
treatment, which yields immediate recanalization, as in
adults. If the thrombolysis could not be applied or balloon
angioplasty failed, the intracranial stenting can be considered as a treatment option.
There are technical difficulties of using magnetic resonance imaging to evaluate postprocedural stent patency due
to stent-induced artifacts [10]. Since stent artifacts, using
sonography, are negligible, transcranial Doppler ultrasonography is useful to show stent patency after insertion. Transcranial Doppler ultrasonography has been in the limelight
because it is a noninvasive technique and can allow continuous bedside monitoring with high accuracy [11]. A normal
value of MCA velocity has not been established in children;
therefore, we compared the right MCA velocity to the left
MCA velocity. Additionally, it is safe in terms of radiation
compared to that of the CT angiography.
We expect that the stent can be occluded in the future.
Therefore, we will monitor the patency of the right MCA
and the formation of collateral vessels with transcranial
Doppler ultrasonography and angiography. In case the
narrowing proceeds, we can consider encephaloduroarteriosynangiosis, which is frequently done in Moyamoya
disease.
In conclusion, there is a relatively high possibility of AIS
in children with congenital heart disease. We can consider
thrombolysis if it is detected within 4.5 hours from onset. If
the thrombolytic therapy is not possible for various reasons,
mechanical thrombolysis can be considered to be an alternative method. This case suggests that intracranial stent
insertion may be a safe and an effective modality in young
children, when the thrombolytic therapy or ballooning is
inapplicable. Additionally, transcranial Doppler ultrasonography is useful in monitoring the cerebral blood flow after
stent insertion in children, as in adults.
Acknowledgments This study was supported by the Samsung Medical
Center Clinical Research Development Program grant, CRS-108-06-1.
Conflict of interest The authors declared no potential conflicts of
interest with respect to the research, authorship, and/or publication of
this article.

Ethical approval Ethical approval for this retrospective study was
provided by the institutional review board of Samsung Seoul Hospital
in Seoul, Republic of Korea.

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