Pediatric Case - Ep.2/2 - SLICE Worldwide 2022 - Cesare DOMINGO

How to choose adequate devices for Childhood stroke ?

Acute ischemic stroke in childhood is a rare condition. Moreover, due to significant delays in diagnosis, treatment is frequently offered late. Knowledge about the effectiveness and safety of endovascular thrombectomy in children is limited. However, existing data suggest that it is feasible and safe. Given the condition’s rarity and the low number of thrombectomy procedures, practitioners may face this life-threatening situation without adequate pre-procedural experience.

Recommendations for interventionalists performing thrombectomy procedures in children:

1. Local neuro-interventional protocols should include childhood stroke;
2. Knowledge of devices that can be used for thrombectomy based on the age/ height of the child is of utmost importance; Since thrombectomy procedures are rare, ideally, childhood stroke protocols should include devices used based on the age of the patient (see Resources)
3. Access should be restricted to the femoral artery; In smaller children, the use of radial introducer sheets is indicated due to their shorter length. In children under five years of age, the diameter of the femoral artery is a significant concern; 4f diagnostic catheters accommodate 0.21/0.17 microcatheters and permit deployment of low-profile stent retrievers;
   
4. Echography-guided puncture permits the evaluation of the size of the femoral artery (the size depends on the child’s height). In older patients with development anomalies, it may be shorter than expected. 
5. Recanalization in young children seems to be comparable to older ones. 
6. Most experts start with a simple aspiration. 5F aspiration catheters that go into 6F guiding catheters can be safely used if the femoral artery accommodates a 6F introducer; 
7. It is debated if stent retrievers are more dangerous in children, so if deemed necessary, they should be used in smaller children, low-profile (3mm), less traumatic stent-retrievers should probably be used; 
   (The complete document is in the resources section)
8. After five years of age, cranial vessels are nearly adult size, so using the usual endovascular armamentarium can be considered; However, in younger children, low-profile material is highly recommended; 
9. Pre-procedural planning, in case of doubt, permits measuring the size of the vessels on the magnetic resonance imaging (MRI) and comparing it with the size of the aspiration catheter;
10. Ensure compatibility between devices before starting the procedure, as the guiding sheet will frequently be less than 8F/9F, unless the procedure is performed in adolescents; 
11. It is possible to advance from the short femoral sheet directly with an aspiration catheter; 
12. Compress manually without blocking the flow in the femoral artery;

Dedicated protocols, including potential devices used, should be set in place in thrombectomy-capable centers to reduce incertitude and delay during a potential emergency.

Device in use:

Chaperon™ by Microvention
Headway™ by Microvention
Sofia™ by Microvention

Envoy™ by Cerenovus

3MAX by Penumbra

pRESET lite by Phenox