Introduction
Ischaemic stroke in infancy is an uncommon but devastating clinical event, associated with high morbidity and long-term neurodevelopmental impairment. Infants with CHD represent a particularly vulnerable population due to altered cerebral perfusion and exposure to cardiopulmonary bypass. Children supported with ventricular assist devices are at particularly high risk, as device-related alterations in flow dynamics, endothelial activation, and haemocompatibility contribute to both thrombotic and haemorrhagic complications. Reference Eisen, Flack and Atluri1,Reference VanderPluym, Kobayashi and Rivkin2
Although stroke is a recognised complication of ventricular assist device support, data describing optimal management strategies in infants remain limited. Endovascular thrombectomy is standard therapy for large vessel occlusion in paediatric acute ischaemic stroke and is associated with improved functional outcomes compared to best medical treatment. Reference Powers, Rabinstein and Ackerson3–Reference Sporns, Sträter and Minnerup5 However, its use in younger children, particularly in infants, remains rare due to concerns regarding vessel calibre, device compatibility, and procedural risk. Reference Rodríguez-López, Gimeno, Vila, Seoane, Ballenilla and Ramos6 We present a 4-month-old infant supported with a single ventricle assist device who developed an acute ischaemic stroke and was successfully treated with endovascular thrombectomy.
Case report
A 4-month-old, 6 kg female with hypoplastic left heart syndrome and a restrictive atrial septum who had previously undergone a Norwood-style arch augmentation with a valved right ventricle-to-pulmonary artery Sano shunt placement. Due to progressive atrioventricular valve regurgitation and severe neo-aortic insufficiency, she was not deemed a candidate for further staged palliation. She subsequently underwent takedown of the conduit, placement of a central shunt, a neo-aortic valve, Park’s stitch, and implantation of a paracorporeal continuous-flow single ventricle assist device.
Postoperatively, she was supported with anticoagulation using bivalirudin and antiplatelet therapy with cangrelor. Approximately one month following device implantation, she developed an acute onset of left-sided weakness. A stroke code was activated at 1.5 hours from her last known well, and computed tomography and angiography of the head demonstrated an acute right hemispheric infarction with areas of hypodensity in the insular region, and some of the supra and infra-ganglionic regions of the right middle cerebral artery territory, corresponding to an ASPECTS (Alberta stroke Program early CT score) of 7, with a CTA demonstrating with occlusion of the M1 segment of the right middle cerebral artery with good pial collaterals from the right ACA (Figure 1).
Computed tomography of the head without contrast demonstrating (a) hypodensity corresponding with acute hemispheric ischaemic changes in the right middle cerebral artery territory and (b) contrasted angiography with occlusion in the M1 segment of the middle cerebral artery.
A multidisciplinary discussion involving neurocritical care, neurointerventional radiology, the ventricular assist device team, and cardiac critical care was undertaken. Given the severity of the stroke and absence of contraindications, the decision was made to pursue endovascular intervention. Aspiration thrombectomy was successfully performed at 7.5 hours from the patient’s last known well with a 038 Socrates® aspiration catheter introduced through a 4Fr groin sheath and navigated over an Excelsior 1018 microcatheter and Synchro 2 soft microwire into the internal carotid artery terminus under continuous aspiration, resulting in near complete reperfusion (Thrombolysis In Cerebral Infarction grade 2C) without procedural complications (Figure 2). Post-thrombectomy imaging demonstrated no haemorrhagic transformation, and cangrelor was restarted while bivalirudin remained therapeutic throughout her course.
Digital subtraction cerebral angiography of the right internal carotid artery: ( a , b ) Frontal and lateral views demonstrating occlusion of the right middle cerebral artery at the M1 segment. ( c , d ) Following aspiration thrombectomy, frontal and lateral views with near-complete reperfusion.
Her postoperative course was complicated by acute symptomatic seizures requiring treatment with multiple antiepileptic medications and infusion therapies with eventual seizure control. She successfully underwent heart transplantation 1 month after her stroke. At the time of her heart transplant and at the time of discharge from the hospital, the patient demonstrated symmetric movement of all extremities without focal neurologic deficits. Antiepileptic therapy was successfully weaned and discontinued altogether during outpatient follow-up.
Discussion
This case demonstrates that thrombectomy can be safely performed in carefully selected infants when performed within an appropriate timeframe and managed by an experienced multidisciplinary team. Prompt recognition of neurologic deficits, emergent neuroimaging, and coordinated decision-making were critical to achieving a favourable outcome. Importantly, institutional preparedness, including an age-specific technical guide that was prepared prior to this case for small-sized infants undergoing endovascular thrombectomy, created by our neurointerventional colleagues, enabled timely and effective intervention.
Despite the favourable outcome, stroke remains a significant source of morbidity in children with CHD, particularly in those requiring advanced cardiac support. Reference VanderPluym, Kobayashi and Rivkin2,Reference Amdani, Shezad and Kroslowitz7 Contemporary registry data demonstrate declining stroke rates and improved survival, particularly in centres with high procedural volume and standardised protocols for anticoagulation, blood pressure management, and neurologic surveillance. Reference Amdani, Shezad and Kroslowitz7 Some institutions have implemented stroke protocols specifically designed for patients on ventricular assist devices, given their unique risk profile and important considerations in both acute neuroimaging and treatment. Reference Mills, Reichhold, Maciorowski, Joong, Kurz and Pardo8
This case also highlights the complexity of anticoagulation management in patients supported with ventricular assist devices who experience an acute ischaemic stroke. Balancing the risks of haemorrhagic transformation against the risk of device and systemic thrombosis presented a significant clinical challenge. In this case, continuation of anticoagulation was carefully weighed against these competing risks, and the patient experienced a favourable outcome. Further investigation is needed to better define optimal anticoagulation strategies, particularly in acutely post-ischaemic stroke, in this high-risk population.
Collectively, these findings contribute to the growing body of literature demonstrating that, with prompt recognition, multidisciplinary coordination, and appropriate patient selection, thrombectomy can be safely performed in infants supported with mechanical circulatory devices. As the use of mechanical circulatory support in infants expands, further study is needed to better define patient selection, procedural safety, and long-term neurologic and cardiac outcomes following thrombectomy in this population.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
None.
