Mechanical thrombectomy for pediatric large-vessel occlusion: a systematic review and meta-analysis with post hoc analysis

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported in abstract; primary outcome CI crosses 1.0 indicating non-significance at conventional threshold

• Effect Size: OR 1.83 (frequentist); OR 1.75 (Bayesian posterior)

• Primary Outcome: Favourable functional outcome in pediatric LVO: MT vs medical management (all comparators combined)

• Nnt Or Sensitivity: NNT not calculable from abstract data. Bayes Factor BF10 5.05 indicates moderate evidence favouring MT for favourable outcome. TSA confirms required information size not reached — additional prospective data mandatory before definitive conclusions

• Confidence Interval: 95% CI 0.97–3.43 (frequentist); 95% CrI 1.05–2.67 (Bayesian). Subgroup MT vs IVT: OR 2.39 (95% CI 1.19–4.79); MT vs conservative: OR 2.22 (95% CI 1.41–3.51). Mortality: OR 1.32 (95% CI 0.45–3.89)

Clinical Application

MT in children requires specialised paediatric neurovascular expertise, appropriately sized endovascular equipment, and multidisciplinary team coordination (paediatric neurology, interventional neuroradiology, paediatric intensive care). Such infrastructure is concentrated in major tertiary centres. Procedural feasibility varies significantly by patient age and vessel size. The evidence does not yet support routine MT outside of experienced centres or clinical trial settings. In Australia, paediatric stroke services are concentrated in major children's hospitals (e.g., Royal Children's Hospital Melbourne, Sydney Children's Hospital, Queensland Children's Hospital). MT for paediatric LVO is not currently supported by TGA-approved indications specific to children, and no PBS-listed pathway exists for this indication. RACGP and Stroke Foundation guidelines follow adult evidence frameworks; the 2023 Australian Clinical Guidelines for Stroke Management do not provide specific recommendations for paediatric MT. Australian clinicians should treat paediatric LVO within multidisciplinary specialist teams, ideally within prospective registry or trial frameworks. The findings of this meta-analysis are consistent with the current Australian position: MT may be considered on a case-by-case basis at experienced centres, but cannot be routinely recommended pending prospective evidence. Children with acute ischemic stroke due to large-vessel occlusion. Pediatric LVO is rare (estimated incidence substantially lower than adult LVO), and the evidence base reflects this rarity. Results may be most applicable to older children and adolescents where vessel anatomy is more amenable to adult-sized thrombectomy devices.

Abstract

OBJECTIVE: To investigate the outcome of pediatric large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). INTRODUCTION: Pediatric LVO is a rare subtype of ischemic stroke. In adults, MT is recommended; however, the efficacy and safety of MT in pediatric LVO are less explored. The available studies are mostly observational studies; yet, these studies show inconsistent findings. METHOD: This review adhered to the PRISMA 2020 guideline. Studies comparing MT with medical management in pediatric with LVO were included. The primary endpoint was the favourable outcome. The mortality rate was sought as well. Subgroup analysis compared MT with intravenous thrombolysis (IVT) and conservative management. Post hoc exploratory analyses comprised Bayesian inference and trial sequential analysis (TSA). RESULT: Six studies comprising a total of 230 MT-treated and 206 non-MT patients were included. In the primary analysis, favourable outcome did not differ significantly between the MT and medical management groups (OR 1.83; 95% CI 0.97-3.43), while supported by exploratory Bayesian inference (OR 1.75; 95% CrI 1.05-2.67; BF10 5.05). Subgroup analysis showed favourable outcomes of MT over IVT (OR 2.39; 95% CI 1.19-4.79) and conservative treatment (OR 2.22; 95% CI 1.41-3.51), although the Bayesian model did not support these findings. The available evidence was insufficient to detect or exclude a difference in mortality between MT and medical management (OR 1.32; 95% CI 0.45-3.89). TSA indicated that the required information size was not reached and that additional trials are needed to reach the minimum sample requirements. CONCLUSION: In this synthesis of observational data, the MT may be associated with favourable outcome in pediatric LVO, however, these findings are hypothesis-generating only. Adequately powered prospective studies are needed before MT can be recommended for pediatric LVO. CLINICAL TRIAL NUMBER: not applicable.

References

1. 1.Hendrawan, F., Chen, J. G., Chandra, G. N., Wicaksono, A. S., & Helal, A. (2026). Mechanical thrombectomy for pediatric large-vessel occlusion: a systematic review and meta-analysis with post hoc analysis. Neurosurgical Review. https://doi.org/10.1136/jnis-2025-023201