What Is the Role of Neurointervention?
Another common question is whether neurointervention has a role in the treatment of pediatric stroke. Recent research, including the Interventional Management of Stroke III study, indicates that IV thrombolysis followed by intra-arterial thrombolysis does not improve outcomes among adults, compared with IV thrombolysis. The official guideline states that the treatment is promising, but that additional randomized controlled studies are needed.
The outcome after endovascular therapy may be predicted by angiographic collateral grade, and children may be better at making collaterals. Outcomes depend greatly on the operator, however, and the procedure carries great risk. Compared with adults, children may be more thrombophilic and more likely to have significant complications such as a clot in the femoral artery, said Dr. Amlie-Lefond. In addition, moving a partial occlusion may transform it into a complete occlusion.
“Would I ever consider a thrombectomy?” said Dr. Amlie-Lefond. “I would not do it in most cases, or even consider it in most cases. I do not think that I would use it to extend the time window, but I would consider it. I would want to be sure that I had an experienced, skilled neurointerventionalist, that I had spoken with the family, and that I was clear about my goals.”
Is Imaging Necessary After Transient Neurologic Deficits?
Neurologists also may be unsure about whether imaging is necessary for a child who has recovered fully from a transient focal neurologic deficit. Clinical experience suggests that it is, said Dr. Amlie-Lefond. One boy was brought to her office after a month of intermittent headache and vomiting. The child’s behavior was normal, but imaging revealed posterior circulation strokes of various ages. Another patient presented after recovering from an episode of left-sided weakness. The girl’s examination results were normal, and she had no risk factors. MRA and MRI, however, revealed that she had moyamoya disease and required management.
Neurologists should perform an MRI and an MRA even if the child appears normal after a focal neurologic deficit, said Dr. Amlie-Lefond. If the child has an arteriopathy, “you have the advantage of getting a warning. We see plenty of strokes where we have missed the warning, and you do not want to miss the warning,” she concluded.
—Erik Greb