Paediatric arterial ischemic stroke is one of the important causes for morbidity, mortality and dependency in children. Incidence of cerebrovascular disorders is observed to be 1.2-7.9 per 100,000 children with posterior circulation involved in 10-30% patients. Stroke in children differs from those in adults in terms of etiology, clinical presentation, management and recovery. The variable clinical presentations and lower incidence of basilar artery occlusion may cause delay in diagnosis and prompt treatment. In absence of recanalization, mortality in basilar stroke is observed to be around 15% while those who survive may have residual deficits ranging from mild dysarthria to bed ridden state. Underlying mechanisms for stroke in children include congenital or acquired cardiac diseases, trauma (especially leading to dissection), vascular (eg Moya Moya disease), hematological (eg Sickle cell disease), infectious and metabolic disorders.
A 6 year old child was referred to NH Health City for consultation with weakness on one side of body which improved with medical treatment given in different hospitals after few days had worsening of symptoms with difficulty in walking, blurred vision and weakness of right side of body and child was tested with MRI and found that the most important artery in the brain (Basilar artery – which supplies our brain stem – which is responsible for our life was blocked). If this vessel is blocked for long the patient will die or will be bedridden in majority of cases. A small tube form the leg artery all the way to brain artery under fluoroscopy. Then a solitaire clot retrieval stent to retrieve the clot. Since the child was 6 year old the artery was very small and it was very challenging to use the devise and retrieve the clot. After removing the clot the child came out of coma in 24 hours, now able to speak, swallow and walk with minimal support.
The solitaire device is a newer addition to the family of clot removal devices which has been approved for use in mechanical thrombectomy. Experience with solitaire has been very limited, especially in basilar occlusion. Bodey et al used Solitaire in three patients with basilar artery infarct and mean time for recanalization was nineteen hours and twenty minutes. MRS of three, two and zero were achieved in these patients at follow up. The common denominators in both these case reports are recanalization beyond eight hours, excellent clinical outcome and absence of reperfusion hemorrhage.
To the best of our knowledge, ours is the first case to report the use of mechanical thrombectomy from Asian continent and is one of the very few examples of use of solitaire device in pediatric posterior circulation stroke.
Until further guidelines and recommendations, mechanical thrombectomy should be considered in carefully selected pediatric population after consultation with pediatric and interventional neurologists.
Dr. Vikram Huded
Consultant – Interventional Neurology