Successful Treatment for Stroke in a Child Using Recombinant Tissue Plasminogen Activator

Thirumalai, Shanti S.; Shubin, Richard

doi:10.1177/088307380001500813

Cited by 66 publications

(29 citation statements)

References 2 publications

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“…There have been several small reports and series of children receiving thrombolytic therapy. [3][4][5][6][7][8][9][10][11] Most involved cases of intra-arterial delivery of thrombolytic (urokinase, tissue plasminogen activator) with varying stroke etiologies, treatment windows, dosages and outcome measures, though largely the immediate results were favorable. Mode of delivery could also not be ascertained, though it is possible that the patients who underwent cerebral angiography on the incident stroke day did so for the purposes of intra-arterial delivery of thrombotics.…”

Section: Discussionmentioning

confidence: 99%

“…Thrombolytic therapies have been shown to be safe and effective in adults, but there is no data in the population below 18 years of age. There are several reports of intravenous and intra-arterial thrombolysis among children, [3][4][5][6][7][8][9][10][11] but national estimates are unknown. We sought to determine rates of thrombolysis for pediatric ischemic stroke as well as associated demographic and clinical data, and compare these between children who did and did not receive thrombolysis in a national government sponsored database.…”

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confidence: 99%

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Thrombolysis for Ischemic Stroke in Children

Janjua

Nasar

Lynch

et al. 2007

Stroke

129

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Background and Purpose-Few pediatric reports of thrombolysis exist. We sought to determine national rates of thrombolysis among pediatric ischemic stroke patients using a national database. Methods-Patients between the ages of 1 and 17 years, entered in the Nationwide Inpatient Sample between 2000 and 2003, with International Classification of Diseases codes for ischemic stroke were included in the study. Differences in mean age, gender distribution, ethnicity, secondary diagnoses, medical complications, associated procedure rates, modes of discharge, and hospital costs between pediatric stroke patients receiving and not receiving thrombolysis were estimated. Results-In the United States, between 2000 and 2003 an estimated 2904 children were admitted with ischemic stroke, of which 46 children (1.6%) received thrombolytic therapy. Children who received thrombolysis were on the average older (11 versus 9 years), more likely to be male (100% versus 53.8%), with significantly higher hospital costs ($81 800 versus $38 700). These children were also less likely to be discharged home with higher rates of death and dependency, although differences in clinical severity between the 2 groups was not known. Conclusion-Thrombolysis, though not indicated for patients Ͻ18 years of age, is currently being administered to children, with unclear benefit. Larger studies are needed to evaluate the safety and efficacy of this treatment for children. (Stroke.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Thrombolysis for Ischemic Stroke in Children

Janjua

Nasar

Lynch

et al. 2007

Stroke

129

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“…Only a few cases, ranging in age from 12 to 16 years, have been reported. [17][18][19][20] There were no complications and all had a good outcome.…”

Section: Childrenmentioning

confidence: 86%

Intravenous Alteplase for Stroke

Keyser

Gdovinová

Uyttenboogaart

et al. 2007

Stroke

148

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Background and Purpose-Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review-There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours.The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started Ͻ3 hours of symptom onset. Patients with minor or improving symptoms can also benefit. Intravenous thrombolysis appears appropriate as first line therapy for posterior circulation stroke. Alteplase can be given to patients with cervical artery dissection, seizure at onset and evidence of acute ischemia on brain imaging, and after carefully weighing risk and benefit in pregnancy and during menstruation. There are anecdotal reports on its use in children, patients with recent myocardial infarction, cardiac embolus, intracranial aneurysm or arteriovenous malformation, prior stroke and recent surgery. There appears to be a substantially increased risk of symptomatic cerebral hemorrhage in hyperglycemic stroke patients. The combined intravenous and intraarterial approach to recanalization appears safe and is currently under investigation in a randomized trial. Conclusions-This document does not intend to change the guidelines but reviews the literature on the use of intravenous alteplase for stroke beyond guidelines and in particular conditions.

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“…Although tPA has been used anecdotally in children with stroke [19][20][21][22][23][24][25][26][27][28][29][30] , no standards regarding dosing, indications/contraindications, or outcome are available. A substantial publication bias also limits the interpretation of these reports [31] .…”

Section: Challenges Addressed In the Tips Study Designmentioning

confidence: 99%

Thrombolysis in Acute Childhood Stroke: Design and Challenges of the Thrombolysis in Pediatric Stroke Clinical Trial

et al. 2009

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Background: Although tissue plasminogen activator (tPA) has revolutionized the treatment of acute ischemic stroke in adults, no thrombolysis trials in childhood stroke have been conducted. Experience in adults cannot be applied to children due to fundamental age-related differences in coagulation systems, stroke pathophysiology and neuropharmacology. Obstacles to acute treatment trials in childhood stroke include delays in diagnosis and minimizing risk in a vulnerable population. Study Design: Thrombolysis in Pediatric Stroke (TIPS) is an international multicenter study to assess the safety of intravenous tPA within 0–3 h and intra-arterial tPA within 3–6 h of onset of arterial ischemic stroke in childhood. Through the International Pediatric Stroke Study, 30 international centers will enroll a total of 48 patients: 24 will be treated with intravenous tPA (0.6, 0.75, 0.9, and 1.0 mg/kg) using the classical dose-finding method, and 24 will be treated with intra-arterial tPA (maximum 0.2, 0.3, 0.4, and 0.5 mg/kg) using a Bayesian dose-finding method. Conclusion: The TIPS trial will be the first clinical trial exploring the safety and feasibility of systemic and local thrombolytic therapy in childhood stroke and the obstacles in conducting such a trial.

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Successful Treatment for Stroke in a Child Using Recombinant Tissue Plasminogen Activator

Abstract: Stroke in childhood is often catastrophic, with major sequelae. We report the first successful use of recombinant tissue plasminogen activator for arterial stroke in a child. The patient recovered with no neurologic deficit.

Cited by 66 publications

References 2 publications

Thrombolysis for Ischemic Stroke in Children

Thrombolysis for Ischemic Stroke in Children

Intravenous Alteplase for Stroke

Thrombolysis in Acute Childhood Stroke: Design and Challenges of the Thrombolysis in Pediatric Stroke Clinical Trial

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