Direct aspiration thrombectomy for pediatric large vessel occlusion: A case illustration and systematic review

Background: Direct aspiration as a first-pass technique (ADAPT) and combined stent-retrieval and aspiration (CSRA) are well-established techniques for endovascular thrombectomy (EVT) in adult large-vessel occlusion (LVO) stroke. However, data on their application in pediatric populations remain limited. Case Description: We report a case of a 2 years old treated with ADAPT for LVO and conducted a systematic review of all reported pediatric cases using aspiration-based EVT (ADAPT or CSRA) through April 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Including our case, 64 pediatric patients from 37 studies were analyzed. ADAPT was used in 29 (45.3%) patients, CSRA in 32 (50.0%), and 3 (4.7%) initially attempted ADAPT but required stent retrieval. Mean age was 9.8 years (standard deviation 5.8); 40.4% were female. Etiologies included cardioembolic (41.3%), idiopathic (34.8%), and others. ADAPT was more common in patients with cardiac conditions ( P = 0.026). Recanalization (thrombolysis in cerebral infarction ≥2b) was achieved in 92.6%, with no significant difference in outcomes between techniques. Mortality was 3.1%. Conclusion: ADAPT and CSRA are feasible and effective techniques for EVT in pediatric LVO, with high rates of recanalization and favorable outcomes across a broad range of ages and etiologies. Differences between techniques were minimal, except that ADAPT was significantly more likely to be used in patients with underlying cardiac conditions.