Accepted Manuscript
A Case of Successful Manual Aspiration Thrombectomy in a Pediatric Patient
Gregory M. Weiner, M.D., Rafey A. Feroze, Nitin Agarwal, M.D., David M.
Pancykowski, M.D., William J. Ares, M.D., Ali Kooshkabadi, M.D., Dana D.
Cummings, M.D., Ph.D., Vincent Carson, M.D., Amin Aghaebrahim, M.D., Brian T.
Jankowitz, M.D.
PII:

S0887-8994(15)30216-2

DOI:

10.1016/j.pediatrneurol.2016.02.006

Reference:

PNU 8852

To appear in:

Pediatric Neurology

Received Date: 2 October 2015
Revised Date:

7 February 2016

Accepted Date: 14 February 2016

Please cite this article as: Weiner GM, Feroze RA, Agarwal N, Pancykowski DM, Ares WJ,
Kooshkabadi A, Cummings DD, Carson V, Aghaebrahim A, Jankowitz BT, A Case of Successful
Manual Aspiration Thrombectomy in a Pediatric Patient, Pediatric Neurology (2016), doi: 10.1016/
j.pediatrneurol.2016.02.006.
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A Case of Successful Manual Aspiration Thrombectomy in a Pediatric Patient

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Gregory M. Weiner, M.D.1, Rafey A. Feroze2, Nitin Agarwal, M.D.1, David M. Pancykowski,
M.D.1, William J. Ares, M.D.1, Ali Kooshkabadi, M.D.1, Dana D. Cummings, M.D.Ph.D.3,
Vincent Carson, M.D.3, Amin Aghaebrahim, M.D.1, Brian T. Jankowitz, M.D.1
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Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh,
Pennsylvania, United States of America

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University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of
America

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Division of Child Neurology, Department of Pediatrics, Children’s Hospital of Pittsburgh,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
Funding Statement
This research received no specific grant from any funding agency in the public, commercial or
not-for-profit sectors.

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Competing Interests Statement
The authors have no personal or institutional interest with regards to the authorship and/or
publication of this manuscript.

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Contributorship Statement
GMW, RAF, NA, and BTJ were involved the design and writing of the paper. DMP, AK, DC,
VC, AA were involved in review of the report.

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Corresponding Author
Brian Jankowitz, M.D.
University of Pittsburgh Medical Center
Department of Neurological Surgery
200 Lothrop Street, Suite B-400
Pittsburgh, PA 15213-2582
P: 412-471-4772
F: 412-647-0989
E: jankbt@upmc.edu

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RUNNING TITLE: Mechanical Aspiration Thrombectomy for Pediatric Stroke

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ABSTRACT
INTRODUCTION: Timely recognition of pediatric stroke at major medical centers is improving and
while treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy
of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to
pediatric patients remains the mainstay of treatment without adequate information available
regarding safety and efficacy in children. Recent trials have demonstrated revascularization and
clinical improvement following endovascular retrieval therapy in adults with acute large vessel
occlusive stroke. Furthermore, mechanical thrombectomy using a variety of techniques has been
successful in numerous pediatric stroke cases reported in the literature.

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CLINICAL PRESENTATION: We present a patient with altered mental status and left hemiparesis
diagnosed with acute ischemic stroke due to blockage of the right ICA terminus most likely
precipitated by end stage heart failure and cardio-embolism. Mechanical Aspiration
Thrombectomy (MAT) using the Penumbra Aspiration catheter without any adjunct surgical
equipment or thrombolytic therapy was used to remove thrombus and treat the patient’s acute
ischemic stroke. Complete recanalization with a TICI score of 2C was observed following the
procedure. The Patient exhibited an 8 point improvement in pediatric NIHSS score within 24
hours.

Pediatric; Acute Ischemic Stroke; Middle Cerebral Artery; Thrombectomy;
Endovascular; Penumbra; Aspiration

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KEY WORDS:

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CONCLUSIONS: MAT is commonly used in hospitals but not usually applied in the setting of
pediatric arterial ischemic stroke. Given its efficacy as described in this study, we encourage a
larger systematic trial to evaluate the use of mechanical thrombectomy in pediatric cases of acute
ischemic stroke.

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INTRODUCTION
Pediatric cerebrovascular disorders constitute one of the ten most common causes of death in
children. An incidence of 1.2 to 13 stroke cases per 100,000 children has been reported.1 In
addition, pediatric stroke is associated with high morbidity and life-long neurologic deficits2.
Increased awareness of pediatric stroke lead to an NINDS-sponsored panel workshop that
recommended development of systematic pediatric stroke registries and studies leading to
clinical trials.2,3
Approximately 87% of strokes in adults are ischemic, while only about 13% are hemorrhagic in
nature. In contrast, only about 50% of pediatric strokes are ischemic. A 3-6% mortality and 70%
risk of lifetime morbidity has been reported for pediatric patients following acute ischemic stroke
(AIS).4 Currently approved acute pharmacologic treatments are limited to heparin, aspirin, and
vitamin K antagonists.6,7

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Recent studies in adults, such as the ESCAPE, EXTEND IA, and MR. CLEAN trials, have
demonstrated successful revascularization and improved clinical outcomes following
endovascular treatment of AIS.8 Extending such treatment to pediatric stroke is expected to be
promising. Mechanical thrombectomy using a variety of methods has been attempted
successfully for pediatric AIS with large vessel occlusion (LVO) in case reports but no clinical
trials have been conducted to prove efficacy. In Class IIb recommendations on endovascular
treatment of pediatric acute ischemic stroke by Ellis et al.,9 mechanical approaches alone or
augmented with tPA are suggested over solitary thrombolytic treatment due to a reduced
hemorrhage rate. As such, we present the case of a 15 year old patient with AIS caused by a right
ICA terminus occlusion treated successfully with mechanical aspiration thrombectomy (MAT).
CLINICAL PRESENTATION

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Clinical History
A 15 year old male patient with a history of hypoplastic left heart syndrome and listed Status 1A
for orthotropic heart transplant presented with right sided MCA syndrome. Stroke symptoms
developed while patient was at home, 5 hours prior to arriving at the hospital. While bending
over to pick up his glasses, the patient developed dizziness, a headache, and left extremity
weakness. A family member discovered him on the ground unable to move his left arm and leg.
On examination, the patient was found to have altered mental status, decreased left sided
sensation, left sided hemiparesis, and right sided gaze preference. He suffered from loss of
spontaneous movement and light touch discrimination in the left arm (3/5) along with left lower
extremity weakness (4/5). His pediatric National Institutes of Health Stroke Scale (NIHSS) score
was 9 at time of presentation. Magnetic resonance imaging (MRI) of the brain revealed ischemic
stroke in the right middle cerebral artery (MCA) distribution (Figure 1A, C, E). Magnetic
resonance perfusion imaging indicated significantly reduced blood flow in the right hemisphere
(Figure 1G). A catheter based cerebral angiogram indicated the presence of thrombus at the right
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internal carotid artery (ICA) terminus (Figure 2A). After consultation with neurology, the patient
was deemed appropriate for endovascular management. The unestablished nature of the
procedure along with associated risks of incomplete thrombus removal and hemorrhagic
conversation were discussed with the pediatric transplant cardiologist and patient’s parents,
Informed consent was obtained. Approximately 8 hours following estimated symptom onset,
mechanical aspiration thrombectomy (MAT) of the ICA terminus and M1 segment was
performed. He returned to the pediatric intensive care unit (ICU) intubated for further
management.

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Surgical Technique
Arterial access was gained using a 5 French (F) micropuncture kit to place a 6F sheath in the
right common femoral artery. The sheath was exchanged for a Penumbra 6F 088 NeuronMax
base catheter which was advanced over a 5F diagnostic catheter into the right ICA. A triaxial
system consisting of a 064 Penumbra ACE aspiration catheter, a microcatheter and a microwire
were advanced into the right ICA occlusion. The microcatheter and wire were removed and the
ICA thrombus was removed by direct manual aspiration thrombectomy (MAT) through the ACE
with a 20cc syringe. Repeated runs revealed a residual right M1 occlusion. The procedure was
repeated in the M1 resulting in, TIMI II/TICI 2Cflow (Figure 2b). The aspiration system was
removed and manual pressure at the groin puncture site was held for 20 minutes.
Revascularization was achieved 8 hours from onset of the patient’s symptoms.

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Postoperative Course
At the pediatric ICU, 5 hours following thrombectomy, the patient was allowed to awaken to the
point where a limited neurologic exam was possible and subsequently extubated. The patient was
able to move all 4 extremities on command. Examination by neurology 8 hours after
intervention revealed Pediatric NIHSS score of 1 point for leg weakness. Follow-up MRI was
performed 5 hours following thrombectomy revealing shrinkage of infarcts (Figure 1B, D, F).
The final volume of the patient’s infarct based upon diffusion weighted imaging was 21 cc. A 24
hour post procedure head CT revealed no hemorrhagic conversion. While there is limited
evidence in the pediatric literation regarding restarting anticoagulation following thrombectomy
for cardioembolic stroke, the current patient was thought to be at risk for another thrombotic
episode. To mitigate this risk, aspirin and low dose heparin were restarted 24 hours after the
thrombectomy. On post procedure day 1, the initial neurological deficits were again noted to be
resolved, except for minimal left sided weakness, corresponding with a pediatric NIHSS score of
1. Milrinone, sotalol, spironolactone, and sildenafil were continued for the patient’s heart
condition and he was discharged. On follow-up neurology evaluation 6 weeks after presentation,
he had pediatric NIHSS score of 0, a left orbit sign, 5-/5 Medical Research Council (MRC)
strength in left arm and leg, and subtle left leg limp on walking. The patient remained healthy
enough to receive a heart transplant 7 weeks later.

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DISCUSSION
We present a pediatric case of AIS due to LVO treated successfully with MAT, resulting in
recanalization of the right ICA terminus and almost complete resolution of neurologic
symptoms. It has been recommended that patients with LVO be considered for endovascular
treatment.9 Our choice of thrombectomy was based on these criteria as well as the patient’s
altered mental status, hemiplegia, and presence of ischemia caused by occlusion as revealed by
magnetic resonance angiography. This intervention was only offered to the family after
thoughtful discussions with the patient’s transplant cardiologists who concluded that
thrombectomy offered the best chance for improved clinical outcome and maintaining the health
of the patient until a heart became available for transplant. The present article is the third report
demonstrating the use of MAT without any adjunct devices, to successfully treat pediatric
stroke.10,11 Successful revascularization with MAT in the present case qualifies it as a potential
treatment for AIS in children.

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Successful endovascular intervention in a number of cases from the literature and the present
report are testament to the potential of mechanical thrombectomy in pediatric AIS treatment.
Table 1 contains a summary of published cases employing mechanical endovascular techniques
for treating pediatric strokes. Twenty seven cases with an age range from 2-17 years have been
included, with regions of occlusion in the anterior and posterior circulation.

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Most cases feature the use of stent retrievers and balloon angioplasty with aspiration platforms
used to a much lesser degree. While all these methods have been successful in providing
complete recanalization and improvement in neurologic symptoms, our use of MAT without any
additional devices and adjunct thrombolytic treatment offers a more cost effective and
straightforward treatment method. The Penumbra Pivotal Stroke Trial demonstrated safe and
effective revascularization for adult AIS secondary to LVO by MAT in patients presenting
within 8 hours of symptom onset.12 Although this trial failed to show improved clinical outcome,
recent studies including the MR-CLEAN, Extend IA, and ESCAPE trials have demonstrated
better clinical outcomes following endovascular stroke management in adults.8 These studies
indicate endovascular pediatric stroke management as a promising potential treatment for
pediatric stroke but systematic trials are needed to establish efficacy and pediatric specific
treatment criteria.

The time from symptom onset to treatment is a crucial factor in determining the type of treatment
method to use in AIS.7 Unfortunately the window of time after onset of AIS in which
thrombolytic or endovascular therapy is safe in children has not been established. In the absence
of better information, adult guidelines are being extrapolated to pediatric stroke. Intravenous
therapy with tissue plasminogen activator (tPA) has been anecdotally effective for pediatric AIS
but examination of outcomes in the form of clinical trials is necessary to quantify risk for
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intracranial hemorrhage and establish safe dosing protocols. Such studies have been stymied by
difficulties in enrolling patients with delays in clinical presentation to healthcare facilities and
delays in diagnosis by healthcare providers. The Thrombolysis in Pediatric Stroke (TIPS) study,
aimed at determining safe dosing protocols and establishing efficacy of tPA administration in
pediatric stroke, was discontinued due to the difficulty in identifying and enrolling patients
within 4.5 hours of symptom onset,13 the therapeutic window for tPA administration in adults.
The average time to treatment in published reports of pediatric AIS is 14 hours.14 In such a time
frame, most patients do not qualify for intravenous tPA based on the adult guidelines.

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In contrast, mechanical thrombectomy may be effective in a more prolonged therapeutic window
compared to tPA administration. Dubedout et al. and Maza et al. have demonstrated
effectiveness of thrombectomy at 6 and 8 hours from symptom onset respectively.15,16 Moreover,
Taneja et al. achieved complete recanalization and neurological improvement at 24 hours
following symptom onset.17 In our study, the ischemic stroke was confirmed at approximately 5
hours following initial presentation and was outside the recommended time for intravenous tPA
administration. This along with the risk of hemorrhage contributed to selecting mechanical
thrombectomy over thrombolytic therapy.

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The patient described is from a subgroup of pediatric stroke cases with a heart failure etiology.
Cerebral arteriopathy, including arterial dissection, is a common cause of pediatric stroke and
accounts up to 80% of pediatric stroke in children with no other predisposing conditions.18
However, the presence of thrombus as the cause of stroke in this case increases the likelihood
that the patient suffered from an embolic stroke in the setting of decompensated congenital heart
disease. The suspicion of cardioembolic stroke as opposed to arteriopathy indicated
thrombectomy via aspiration for the described case.

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Grunwald et al., Rhee et al., and Alnaami et al., have also demonstrated mechanical
thrombectomy as a treatment for AIS of the anterior circulation in the setting of chronic heart
failure.10-19 With the significantly improved treatment of congenital heart disease, embolic
strokes to large vessels in the anterior cerebral circulation are likely to be more frequently
encountered at busy pediatric heart centers. As in this case, these patients may benefit from
endovascular management of AIS, preventing morbidity and improving survival until a heart
transplant is possible. However, the paucity of such cases makes it challenging to evaluate the
benefit of endovascular treatment in this patient population.
CONCLUSION
This case report provides support for mechanical thrombectomy using a lone aspiration platform
for effective treatment of embolic stroke precipitated by decompensated heart failure in a
pediatric patient. The approach provides a simple and effective alternative to thrombolytic
therapy or more complicated thrombectomy devices. Pediatric neurologists and neuroPage 6 of 12

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interventionists will have to continue working together to validate endovascular treatment in the
pediatric population.

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FIGURE LEGENDS

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Figure 1. A,C,E) Magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI)
confirms acute ischemic infarction in the right MCA territory (restriction marked by rectangle)
pretreatment. B,D,F) MRI DWI sequences 8 hours post treatment. G) Magnetic resonance
perfusion imaging (MRP) indicates markedly reduced blood flow in the right hemisphere prior to
thrombectomy. H) Pre-thrombectomy MRP indicating corresponding cerebral blood volume.

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Figure 2. A) Catheter angiography showing obstruction of the right ICA terminus (posteroanterior view). B) Post-treatment follow up of catheter angiography illustrates recanalization of
right MCA after thrombectomy (postero-anterior view). C) Coronal view of magnetic resonance
angiogram showing occluded right MCA (arrow). D) Follow up 8 hours later showing restoration
of blood flow.

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Table 1. Review of pediatric stroke cases treated with mechanical thrombectomy.
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