ABSTRACT
BACKGROUND: Arterial ischemicâ¯stroke in children comes with the potential for morbidity and mortality and can result inâ¯high cost of care and decreased quality of life among survivors. Children with arterial ischemicâ¯stroke are increasingly being treated with mechanical thrombectomy, but little is known about the risks and benefits 24â¯hours after a patient's last known well (LKW) time. METHODS: A 16-year-old female presented with acute onset of dysarthria and right hemiparesis with LKW time 22â¯hours prior. Pediatric National Institutes of Health Stroke Scale score was 12.â¯Magnetic resonance imaging showed diffusion restriction and T2 hyperintensity primarily in the left basal ganglia. Magnetic resonance angiography revealed left M1 occlusion. Arterial spin labeling showed a large apparent perfusion deficit. She underwent thrombectomy with TICI3 recanalization 29.5â¯hours after LKW time. RESULTS: At 2-month follow-up, her examination showed moderate right-hand weakness and mild diminished sensation of the right arm. CONCLUSIONS: Adult thrombectomy trials include patients up to 24â¯hours from their LKW time and suggest that some patients maintain a favorable perfusion profile for over 24â¯hours. Without intervention many go on to experience infarct expansion. The persistence of a favorable perfusion profile likely reflects robust collateral circulation. We hypothesized our patient was relying on collateral circulation to maintain the noninfarcted areas of her leftâ¯middle cerebral artery territory.â¯Owing to concern for eventual collateral failure, thrombectomy outside of the 24-hour window was performed. This case serves as a call to action to better understand the impact of collateral circulation on cerebral perfusion in children with large vessel occlusions and delineate which children may benefit from thrombectomy in a delayed time window.
Subject(s)
Brain Ischemia , Ischemic Stroke , Stroke , Female , Humans , Adolescent , Child , Stroke/diagnostic imaging , Stroke/etiology , Stroke/surgery , Quality of Life , Thrombectomy/methods , Infarction, Middle Cerebral Artery/diagnostic imaging , Infarction, Middle Cerebral Artery/surgery , Cerebrovascular Circulation , Treatment Outcome , Brain Ischemia/diagnostic imaging , Brain Ischemia/surgeryABSTRACT
Arterial thoracic outlet syndrome is a rare condition characterized by compression of the subclavian artery, often with post-stenotic aneurysm formation. Artery-to-artery embolic strokes related to thoracic outlet syndrome have been reported in the posterior circulation and in the ipsilateral anterior circulation. We present a case in which a thrombus secondary to thoracic outlet syndrome caused a contralateral anterior circulation stroke in an adolescent and postulate mechanisms of this rare occurrence. This case demonstrates that a subclavian thrombus due to thoracic outlet syndrome can take a circuitous path and cause an anterior circulation stroke contralateral to the diseased subclavian artery. In addition, this case illustrates the importance of a high index of suspicion for thoracic outlet syndrome in patients with stroke and associated arm pain or discoloration.