Complications of Therapies for Ischemic Cerebrovascular Disease in Children

Surgical

Endovascular

Complications of endovascular intervention for pediatric ischemic stroke include access site and interventional complications. Studies of both pediatric and adult cohorts indicate that more severe periprocedural complications occur in fewer than 5% of patients (92,215,257,258).

• Interventional complications: These include intracranial hemorrhage, air emboli, distal embolization, vessel dissection, and transient vasospasm.
• Access site complications: There may be complications at the groin access site, including hematoma formation. A small hematoma may be expected, but a large and expanding hematoma is cause for concern. Femoral ischemia, which is more common in neonates and infants, may occur due to thrombosis at the access site. This may be managed with anticoagulation to preserve perfusion to the distal lower extremity (250).

Decompressive Craniectomy

Decompressive craniectomy may be a life-saving procedure for some children with malignant stroke. However, it is associated with several complications, which may be intra- or postoperative. A reasonable estimate of the complication rate in children cannot be determined due to lack of data in the literature; however, in adult cohorts, the overall complication rate has been reported as high as 53.9%, with 23.6% of patients developing more than one complication (259).

• Intraoperative complications: These include hemorrhage and injury to the dural venous sinuses (239,260).
• Wound complications: These include dehiscence, ulceration, and necrosis (260).
• External cerebral herniation: Brain tissue may herniate through the craniectomy defect in up to 25% of adult patients (260).
• CSF leak: This may occur in up to 6.3% of adult patients (260).
• Postoperative infections: These may occur in up to 10% of adult patients (260).
• Seizures: Seizure activity may be detected in more than half of adult patients who undergo decompressive craniectomy, although the risk of this complication may be mitigated with anticonvulsant medications (260).
• Subdural and subgaleal hygromas: These may form due to abnormalities in CSF flow; subdural hygromas may form in up to 12.5% of adult patients (260).
• Hydrocephalus: CSF disturbances leading to hydrocephalus may occur in some patients; adult incidence estimates vary considerably (260).
• Syndrome of the trephined (sinking skin flap syndrome): This complication, which may occur in up to 10% of adult patients, is associated with severe headache and neurological deficits (260,261). In such cases, the skin flap may exert pressure on the underlying cerebral cortex and induce blood flow abnormalities (260).
• Direct mechanical injury to decompressed region: Brain injury may occur when the decompressed region is subjected to direct mechanical injury (239). Absence of the bone flap must be clearly indicated and the risk of injury communicated to the care team and family members to prevent this complication.

Medical

• Antithrombotic medications and fibrinolytics: Antiplatelet and anticoagulant medications may increase the risk of bleeding; aspirin in particular is associated with serious gastrointestinal bleeding (261). IV tPA or TNK may result in bleeding complications such as symptomatic intracranial hemorrhage, although the estimated risk of this serious complication is only 2.1% in children (262).
• Drugs for inflammatory etiologies: Drugs that may be considered for secondary stroke prevention in the setting of an inflammatory etiology may have several complications, including infection due to immunosuppression (263).

Other Therapies

• Chronic blood transfusions: HbSS patients receiving frequent blood transfusions for stroke prevention are at risk of several complications, including iron overload, transfusion-acquired infections, alloimmunization, transfusion reactions, and hyperviscosity syndrome (which may lead to CVST or cerebral infarction) (62,264).