Neurosurgeons Place Stroke-Preventing Stent in Adolescent

Neurosurgeons at UB successfully implanted a stent in an artery inside the skull of a 14-year-old boy to prevent a stroke, a procedure thought to be the first conducted in an adolescent.

The boy was home within one day and remained well at his nine-month evaluation.

A full description of the surgery, which took place in September 2009, appears in the August 2010 issue of the Journal of Neurosurgery: Pediatrics.

Elad Levy, MD, UB associate professor of neurosurgery and senior author on the paper, says that the boy’s injury, an “intracranial arterial dissection” in medical terms, is an important cause of stroke in young patients.

An arterial dissection is a tear along the inside wall of an artery. As the tear becomes larger, it forms a small pouch. As the blood accumulates in the pouch and blocks the artery, it can result in a stroke.

“Most arterial dissections in adults occur in the carotid artery outside the skull on either side of the neck,” says Levy, who was the attending surgeon on the UB neurosurgery team. “However, in children, the location is often intracranial, or inside the skull. To date, treatment, although controversial, is typically medical, either with anti-platelet medication or anticoagulation therapy.

“However, neurosurgeons now can treat the dissection more effectively with the advent of self-expanding intracranial stents,” Levy says. “Our team at UB is very pleased with the outcome in this patient.”

The boy was injured when he fell off a chair and hit the right side of his forehead. “Shortly thereafter, his parents noted a left facial droop and some left-sided weakness,” says Levy. “They took him to an emergency room, but by the time he arrived, the symptoms had completely resolved.

“However, about 48 hours later, outpatient imaging suggested a possible stroke and the boy’s pediatrician referred him to the UB. We saw him in our neurosurgery clinic that day [at Millard Fillmore Gates Circle Hospital of Kaleida Health] and he underwent diagnostic scans, which showed the dissection.”

The neurosurgical team guided a catheter through the carotid artery to the injury site and deployed an expanding stent to cover the damaged area. The boy left the hospital after a day’s stay in the hospital and was prescribed aspirin and a drug to prevent blood clotting. At the nine-month follow-up he was well, blood flow was normal and there was no evidence of blockage in the stent, according to the surgeons.

“Committing a pediatric patient to a lifetime of intracranial hardware is not a decision taken lightly,” states Levy. “However, modern stents offer dramatically improved results. In this case, we thought it was a better option for him to live with the ‘hardware’ in his skull than to face a life of potential stroke-related disability.

“Stroke in young patients accounts for as much as 20 percent of the potential life-years lost due to stroke, so stroke prevention in the pediatric population has the potential for significant societal benefit,” he adds.

Levy notes that this case offers an example of the expanding potential of intracranial stenting.

“Given the unforgiving morbidity of traumatic intracranial dissections in the pediatric population, and the paucity of strong medical alternatives, the potential to avert debilitating strokes in the young merits aggressive investigation.

“This case offers a critical first step in what may turn out to be a promising treatment for traumatic intracranial dissections in children,” he says, “and may lead to new ways of treating diseases that previously have been untreatable.”

Mandy J. Binning, MD, UB endovascular/neurovascular fellow, is first author on the paper. Additional contributors, all from the UB Department of Neurosurgery, are Alexander A. Khalessi, MD, neurosurgery fellow; Adnan H. Siddiqui, MD, PhD, assistant professor; and L. Nelson Hopkins, MD, professor and department chair.