A friend in need is a friend indeed – Ischemic stroke case where SOFIA™ made all the difference

Discover the intricate case of a pediatric basilar artery occlusion following a seemingly minor fall. This clinical case showcases the rapid diagnostic process with CT and MRI/MRA, and the mechanical thrombectomy performed using SOFIA™ 5F 115cm. Learn how a multidisciplinary team's swift intervention and advanced techniques led to a full recovery, underscoring the critical importance of specialized, timely care in pediatric stroke management.

Diagnosis

After being admitted and clinically examined by the neuropediatrician the patient was sent for urgent non-contrast CT since there was information of his fall from the chair in the kindergarten.
CT revealed hyperdense portion of the distal basilar artery (BA), and there were no substantial CT findings in sense of suspected head contusion nor intracerebral haemorrhage.

The boy has been then urgently transferred to the brain MRI/MRA examination which showed FLAIR / DWI mismatch with MRA proof of the occlusion of basilar artery.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 1

Management, evolution, and follow-up

After presenting further treatment strategy to the attending neuropediatrician, and the family of the boy by interventional neuroradiologists (Bulja D. and Abud AO.) it was decided to refer the patient for mechanical thrombectomy due to emergent basilar artery occlusion.

Upon discussion with the anesthesiologists having in mind clinical status of the child, it was decided to perform mechanical thrombectomy in conscious sedation (CS).
Right common femoral artery was punctured and 5F introducer sheath has been placed.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 2

5F Vertebral catheter and hydrophilic 0.032’’ guide wire have been used to catheterize left vertebral artery.
Exchange maneuver has been subsequently performed for placement of 6F long sheath at the level of left subclavian artery and finally 5F SOFIA™ 115 cm has been introduced to V2-V3 segment of left VA following another angiography run which confirmed distal basilar artery occlusion.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 3

Direct aspiration has been performed in three attempts after navigating a SOFIA™ 5F 115cm up to the face of the clot and forceful suction.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 4

Final angiography run confirmed full patency of basilar artery.

Extracted thrombi were pinkish-white in colour and stiff. They clogged the aspiration catheter during suction manoeuvres so cardiac origin was suspected.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 5

Non-contrast CT has been performed 24h after the procedure which did not reveal significant ischemic lesions in the brainstem with child’s mRS 1.

Three months later follow-up brain MRI/MRA has been performed that showed completely patent basilar artery and without the presence of ischemic lesion in the brainstem.
At that time, the boy had mRS 0.

A friend in need is a friend indeed – Ischemic stroke case there SOFIA made all the difference - Figure 6

Clinical work-up after thrombectomy revealed post COVID condition with induced thrombophilia and thrombus in the left atrial appendage so the long-term anticoagulant therapy with Rivaroxaban was introduced.
Since then, the patient is in good health without neurologic deficits.

Conclusion and key points

Acute ischemic stroke due to emergent large vessel occlusion is a devastating disease, whether it happens in adulthood or childhood
De Veber et al. reported a mortality rate after childhood stroke between 2.6 and 5% with the emergence of persistent neurological deficits in 60% of neonates and 70% of children, of which, 36% were mild, 23% were moderate, and 10% were severe deficits¹
Physicians approaching to ischemic pediatric stroke should consider several differences versus adults that represent remarkable clues for the diagnosis and the treatment such as non-atherosclerotic arteriopathies, thromboembolic complications of congenital cardiopathies and hematologic disorders²
The management of acute ischemic stroke as a consequence of large vessel occlusion should be discussed and managed in multidisciplinary teams (MDT)
The management is challenging especially in the children because of frequent atypical clinical presentation, and the lack of evidence-based data about hyperacute recanalization therapies.
It is very important to speed up the implementation of paediatric acute stroke protocols that could lead to better and faster recognition and diagnosis of acute ischemic stroke in children, making the delivery of hyperacute recanalization treatment feasible.

References

deVeber GA, Kirton A, Booth FA, et al. Epidemiology and outcomes of arterial ischemic stroke in children: the Canadian Pediatric Ischemic Stroke Registry. Pediatr Neurol. 2017;69:58–70.
Mastrangelo M, Giordo L, Ricciardi G, De Michele M, Toni D, Leuzzi V. Acute ischemic stroke in childhood: a comprehensive review. Eur J Pediatr. 2022 Jan;181(1):45-58

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