The Youngest Challenge: Emergency Stenting for Pediatric Ischemic Stroke

Medical History & Background

• Family: Strong thrombotic predisposition (Mother/Aunt: Factor VIII overproduction; Paternal Grandfather: Multiple TIAs).
• Personal: Recurring headaches since age 6; otherwise healthy and active.

Timeline of the Event (Jan 23rd)

• Late Afternoon: Developed back pain, migraine with ocular involvement, and abdominal pain during basketball practice.
• 20:30 (Onset): Sudden loss of balance and collapse while at a party.
• Initial Symptoms: Confusion, delayed responses, tremors, nausea/vomiting, and loss of fine motor skills.
• 21:30 (ER Admission): Arrived stable but confused; toxicology screen was negative.
• Clinical Decline: Developed expressive difficulties (anomic aphasia) and left-sided hypotonia.

Clinical Evolution (Jan 24th)

• 04:00: Admitted to Pediatrics; Initial non-contrast CT was negative.
• 12:00 (Neurological Consultation): Significant worsening with fluctuating symptoms.
• Exam: Left hemiplegia and complete facial nerve palsy.
• Severity: NIHSS: 12 | PedNIHSS: 13
• 16:40 (Advanced Imaging): Urgent workup including MRI (DWI/FLAIR), CECT, CTA, and Perfusion CT.

Baseline CT

MRI  15:00

Perfusion imaging is feasible in children, but:

• Cutoffs for defining the ischemic core and penumbra are not yet standardized; however, some studies suggest that EVT (Endovascular Thrombectomy) can improve outcomes in patients with clinical-radiological mismatch and salvageable brain tissue

Femoral sheath 6F - Benchmark 105 cm - Vertebral 5F 120 cm

Sofia 5F – 1 ADAPT

Sofia 5F - Trevo Pro 21 - pReset 4x20mm - Embotrap III 5x22 mm

1,5 mg Nimodipine

Neurospeed 3 x 8 mm

pEGASUS 4,5 x 20 mm

 

Tirofiban Bolus: 21 ml - Maintenance: 229 ml at 7 ml/h for 12 h - Overlapped at 10 hours with Clopidogrel 75 mg

• 24 hours later NIHSS: 12 --> 10 (minimal recovery of mobility in the lower limb)
• 36-48 hours later: slight left hemiparesis
• 6 days later: no deficits

6 days later MRI

• PFO? Observed on post-thrombectomy echocardiogram; small, not hemodynamically significant. Subsequent bubble test was negative.
• Coagulopathy? Family history significant for Factor VIII alteration on the maternal side with a positive family history of thrombosis. However, genetic testing, homocysteine levels, and Factor VIII assay were negative.
• FCA-I (Inflammatory Focal Cerebral Arteriopathy)? Child vaccinated for varicella; no history of recent infections. Furthermore, although not performed immediately after the event, vessel wall imaging showed no signs of parietal inflammation.
• FCA-D (Dissection-related Focal Cerebral Arteriopathy)? Although unclear—as it was initially reported, then denied, then reported again—the child allegedly complained of a headache at the party. Additionally, the child has a history of headaches since third grade, with a frequency of 10 days per month.
• Vasculitis?
• Early-stage Moya-Moya?

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