Are children with acute arterial ischaemic stroke eligible for hyperacute thrombolysis? A retrospective audit from a tertiary UK centre

Abstract

Aim The aim of this study was to evaluate the number of children with acute arterial ischaemic stroke (AIS) who would have been eligible for hyperacute thrombolysis in the authors' unit (Great Ormond Street Hospital, London, UK) and to identify barriers to this treatment. Method We compared the characteristics of children with a diagnosis of acute AIS, identified from neuroimaging databases, seen at our centre between January 2006 and December 2011. The criteria for hyperacute thrombolysis were predefined by us: age ≥8y; imaging‐confirmed diagnosis of acute AIS and arrival at our centre within 6 hours of symptom onset; occluded major artery on computed tomography (CT) or magnetic resonance angiography; no contraindications. Factors that precluded therapy were examined. Results Of a total of 107 children with acute AIS identified on MRI (n=64; 33 females, 31 males; median age 4y, range 1mo–17y) or CT databases (n=43; 14 females, 29 males; median age 1y, range 1mo–15y), none would have been eligible for hyperacute thrombolysis. The major barriers to this were (1) delayed diagnosis, (2) delayed transfer to the tertiary centre, (3) age, and (4) medical comorbidities. Of 107 children, three (2.8%) would have been eligible for thrombolysis if diagnosis and transfer had occurred in a timely manner. An additional 11 children (10.3%) would have been eligible if the age criterion was 28 days or more and if diagnosis and transfer had occurred promptly. Interpretation Although hyperacute thrombolysis is, as yet, an unproven treatment in childhood AIS, at least a subset of patients could potentially benefit. This audit has identified that clinical factors preclude treatment in a high percentage of children. Furthermore, in our specialist unit, without an emergency department, we identified major logistic barriers that will need to be addressed to enable access to hyperacute therapies. These results could inform future trial design and service delivery.

Susceptibility-Weighted Imaging in Pediatric Arterial Ischemic Stroke: A Valuable Alternative for the Noninvasive Evaluation of Altered Cerebral Hemodynamics

“…Although the benefit of thrombolytic therapy in PAIS has yet to be demonstrated in prospective clinical trials, retrospective studies show that at least a subset of children with AIS may potentially benefit from it. 21,22 Several tertiary pediatric centers have developed standardized systematic strategies to diagnose and treat PAIS, for participation in the ongoing Thrombolysis in Pediatric Stroke trial. 21,22 Ischemic penumbra can be depicted as a mismatch between reduced perfusion and normal diffusion by combining PWI and DWI/DTI.…”

“…21,22 Several tertiary pediatric centers have developed standardized systematic strategies to diagnose and treat PAIS, for participation in the ongoing Thrombolysis in Pediatric Stroke trial. 21,22 Ischemic penumbra can be depicted as a mismatch between reduced perfusion and normal diffusion by combining PWI and DWI/DTI. 23 In children, however, the routine application of PWI outside research protocols and tertiary care centers is still limited.…”

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

“…In a large retrospective cohort analysis, Mallick et al reviewed 107 pediatric patients and found that only three patients would have been eligible for hyperacute thrombolysis with IV tPA. 56 This study and the slow recruitment of patients to the TIPS (Thrombolysis In Pediatric Stroke) trial demonstrates the degree of difficulty in achieving timely access to thrombolytic therapy in the pediatric patient group. Since 2015 the established benefit of MT in adults has shown tremendous improvement in neurological function in recanalized patients in real-world application of randomized trial results.…”

Acute Ischemic Stroke in Children – Should We Thrombolyze?

“…Marecos et al . [ 13 ] subsequently reported a retrospective 5-year audit on the eligibility for thrombolytic therapy in a tertiary center in the UK. The aim was to define local criteria for children with hyperacute ischemic strokes who might benefit from thrombolysis, to examine how many would have met these criteria, and to describe the barriers to hyperacute treatment in childhood ischemic strokes.…”