Eligibility for Thrombolysis for Pediatric Acute Ischemic Stroke.
This retrospective multicenter cohort found that 26 of 139 symptomatic pediatric acute ischemic strokes were potentially eligible for tPA under current recommendations and identified selected small-vessel strokes as a possible population for future eligibility expansion.
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This retrospective multicenter cohort found that 26 of 139 symptomatic pediatric acute ischemic strokes were potentially eligible for tPA under current recommendations and identified selected small-vessel strokes as a possible population for future eligibility expansion.
Research significance
Evidence: guideline-based retrospective review classified 19% of pediatric strokes as potentially tPA-eligible, while some small-vessel strokes had no additional stated contraindications. Inference: prospective safety and efficacy studies could determine whether carefully selected children with small-vessel stroke—and potentially other currently excluded groups—might benefit from expanded thrombolysis eligibility; this record does not establish benefit, safety, or suitability in children with brain tumors.
Source abstract
BACKGROUND: Thrombolysis is infrequently delivered to children with acute ischemic strokes (AIS). We explored potential eligibility for treatment with tPA (tissue-type plasminogen activator) for pediatric AIS. METHODS: This retrospective, multicenter, observational, cohort study reviewed children aged 29 days to 17 years with symptomatic AIS identified via Children's Hospital Westmead, John Hunter Children's Hospital, and Sydney Children's Hospital between January 1, 2010, and December 31, 2019. Medical records were examined to evaluate eligibility for treatment with tPA based on established multinational and the 2026 American Heart Association guidelines, reasons for exclusion beyond delay to diagnosis, and long-term outcomes as pediatric modified Rankin Scale scores. We also explored additional exclusions and outcomes among children with small-vessel AIS and AIS in the context of brain tumors, who are currently excluded from tPA. RESULTS: A total of 135 patients with 139 symptomatic AIS were identified-median age, 6 years; 36% female; 73% presented via emergency departments; mean follow-up, 43 months; 12% deaths. Irrespective of delay to diagnosis, only 26 of 139 (19%) AIS were potentially eligible for treatment with tPA. Among patients potentially eligible for tPA, acute neuroimaging revealed large-vessel occlusions, unilateral focal cerebral arteriopathy, or extracranial dissections. Thirteen of 26 (50%) had nondisabled outcomes without tPA treatment. One hundred thirteen of 139 (81%) AIS were ineligible for treatment with tPA, irrespective of delay to diagnosis. All deaths occurred among patients excluded from tPA, predominantly related to underlying disorders. Fifty-four small-vessel AIS accounted for 39% of AIS. Eighteen (33%) had no additional ineligibilities to thrombolysis, among whom 10 had nondisabled outcomes without tPA. CONCLUSIONS: Based on current recommendations, 19% of symptomatic childhood AIS were potentially eligible for treatment with tPA, irrespective of delay to diagnosis. Selected patients with small-vessel AIS may offer an opportunity to extend the role of tPA. These observations may be relevant for optimizing pediatric stroke management strategies.