Aspirin in childhood acute ischemic stroke: The evidence for treatment and efficacy testing

Abstract

Aspirin is the most commonly prescribed antiplatelet agent worldwide, but evidence supporting its use varies by age and disease process. Despite its frequent use in childhood acute ischemic stroke prevention and management, major knowledge gaps exist about optimal pediatric aspirin use, particularly in this setting, where high‐quality clinical trials are urgently needed. This review focuses upon the evidence for aspirin use in childhood acute ischemic stroke, includes a summary of aspirin pharmacology to highlight misconceptions and common clinical situations which may limit its efficacy, and discusses the techniques and potential role of laboratory monitoring of aspirin efficacy in children.

Urinary 11‐dehydrothromboxane B2 aspirin efficacy testing is sensitive to perioperative inflammation in pediatric solid‐organ transplant patients

“…In some settings, it connotes laboratory‐based ex vivo testing demonstrating inadequate platelet inhibition in the presence of aspirin, whereas alternatively it may suggest clinical pharmacologic failure (i.e., thrombosis or ischemic infarct despite being on the medication) 10 . Functional efficacy can be impacted by several factors, both biologic and iatrogenic, and is better termed “high on‐treatment platelet reactivity.” 1 High on‐treatment platelet activation is proposed to result from the inducible cyclo‐oxygenase 2 (COX2) pathway in the setting of inflammation. Although aspirin inhibits COX1, it has little effect on COX2‐mediated thromboxane A2 production (sometimes termed nonplatelet thromboxane), 11,12 thus contributing to continued platelet reactivity despite adequate COX1 inhibition.…”

“…Pediatric aspirin efficacy testing is less well studied, particularly for noncardiac patients, and age‐based therapeutic ranges have not been validated. Even in adults, comparative data of aspirin efficacy across these and other test platforms have shown discordance 1,3 . A subtherapeutic result for aspirin's effect on platelet reactivity, as measured by VN in congenital heart disease patients, has been associated with higher thromboembolic risk in single‐site prospective studies 4,5 .…”

“…Aspirin has been widely used in pediatric patients with congenital and acquired heart disease for primary or secondary thromboprophylaxis 1 ; however, dosing and management strategies have generally been based upon expert recommendations and side‐effect reduction (bleeding and bruising) rather than on aspirin efficacy monitoring 2 . Aspirin efficacy monitoring platforms were primarily developed for adults with acute coronary syndrome, which include current United States’ Food and Drug Administration (FDA)‐approved whole blood testing of residual platelet reactivity (VerifyNow‐Aspirin, VN) and an immunoassay for the urinary thromboxane metabolite 11‐dehydrothromboxane B2 (AsprinWorks, UTxB2).…”

The Role of Folate Deficiency as a Potential Risk Factor for Nontraumatic Anterior Spinal Artery Syndrome in an Adolescent Girl

“…Except for low serum folate levels (1.7 ng/mL, reference range: 4.8–37.3) and mildly increased LDL cholesterol levels (114 mg/dL, reference range: <100), no other abnormalities were identified in the patient. The patient received a five-day course of high-dose intravenous methylprednisolone to ameliorate the spinal cord edema, aspirin for the anticoagulation [ 11 ], and folic acid supplementation for the marked folate deficiency ( Table 1 ). When folate levels were rechecked two weeks later, they were restored to normal levels (12.2 ng/mL).…”

Childhood Arterial Ischaemic Stroke: Clinical Presentation, Risk Factors and Management

“…To standardize and optimize the use of antithrombotic therapy in childhood AIS, further studies with a focus, amongst others, on efficacy, dosing, impact of developmental haemostasis, treatment monitoring and duration are needed. 65…”