Decompressive Craniectomy in Pediatric Stroke

The evidence base for stroke treatment in children lags behind that of adults in many ways. The “Save ChildS” trial recently showed that thrombectomy for acute stroke is beneficial in children. However, this result is based on a relatively small number of patients and only addresses the reopening of the acute arterial occlusion. Even if the vessel is successfully reopened, a more or less large infarct cannot be avoided entirely in many cases in both adults and children. If the infarct area is large enough, a new danger can arise for the patient, to which children are more susceptible than adults: malignant cerebral edema, which can take up so much space in the form of swelling of the infarcted brain that other parts of the brain are damaged or even trapped, with the risk of death. In adults, there is evidence that decompressive craniectomy (DC) improves survival and outcomes after a massive stroke. This evidence is not yet available for children. We present the case of a 3-year-old boy with a wake-up stroke. There was an embolic occlusion of the right distal internal carotid artery and the middle cerebral artery. Due to the lack of leptomeningeal collaterals of the right middle cerebral artery and an interval of several hours between clinical onset and successful mechanical thrombectomy, complete infarction of the affected territory occurred. Computed tomography scans in the first hours after thrombectomy showed increasing infarct swelling and impending herniation. A right decompressive hemicraniectomy was performed on the first day of treatment. Despite the large right hemispheric infarct, which involved the entire territory of the right middle cerebral artery, there was a marked clinical improvement in the following months (mRS 1). This case illustrates the importance of early follow-up imaging and neurosurgical intervention in pediatric patients with large-volume infarction despite successfully reopening an occluded intracranial artery. Decompressive craniectomy is an integral part of pediatric stroke management.