study, there were 14 children with stroke, an occluded artery, and no thrombolysis contraindications. Of these 14, three were infants, three had delayed presentation due to lack of stroke recognition by their family, and two had delayed diagnosis due to stroke recognition by medical providers. The additional six children were all delayed by transport to the quaternary center but otherwise appear to have met criteria for thrombolysis as per the TIPS trial. The lack of an emergency department certainly delayed arrival of children with stroke to this center. Therefore, perhaps eight out of 107 (7.4%) would have been eligible without delays in diagnosis or transport. Of note, tPA is utilized in approximately 5% of adults with acute stroke.4 Typical time windows are 4.5 hours from stroke onset for intravenous tPA and up to 6 hours for off-label intra-arterial thrombolysis for adult stroke. TIPS utilized a 4.5 hour standard for intravenous tPA. In terms of stroke severity, the adult standard is to give tPA for an NIHSS of 4. The initial TIPS trial required a PedNIHSS of at least 6 and then dropped this to 4 to aid recruitment and parallel adult studies. The current study utilized a PedNIHSS of 10 as the authors’ threshold for an unproven therapy (tPA). For reference, flaccid paralysis of one limb is recorded as a PedNIHSS of 4.2

The study is important is shows that there will be practice variability for off-label use of stroke thrombolysis in children unless convincing studies can be done. Furthermore, this study highlights the importance of ‘pediatric stroke centers’. The TIPS investigators noted that at the beginning of the trial that less than 25% of TIPS sites had continuous 24-hour availability of acute stroke teams, 24/7 sedated magnetic resonance imaging capability, or stroke order sets, despite significant pediatric stroke expertise.5 After TIPS preparation, more than 80% of sites had these systems in place. The actual number of children who qualify for tPA may be small due to delays in presentation for medical care, delays in diagnosis of stroke, and comorbid medical conditions that make them ineligible. However, in clinical trials in adult stroke, two acute stroke treatments clearly save lives and improve neurological outcome: the use of tPA and dedicated stroke units to provide supportive, acute post-stroke care to prevent complications. Therefore, when acute stroke is considered in the differential diagnosis for a child, rapid transfer to a pediatric medical center with pediatric stroke expertise and readiness for rapid evaluation and treatment is critically important. Regional pediatric stroke centers should be developed to provide the best care.

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5. Bernard TJ, Rivkin MJ, Scholz K, et al. Emergence of the

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2. Ichord RN, Bastian R, Abraham L, et al. Interrater reli-

4. Bambauer KZ, Johnston SC, Bambauer DE, Zivin JA.

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Risk of cerebral haemorrhage in children with sickle cell disease ADEKUNLE ADEKILE Department of Pediatrics, Kuwait University, Safat, Kuwait. doi: 10.1111/dmcn.12585 This commentary is on the original article by Kossorotoff et al. on pages 187–193 of this issue.

Ischaemic stroke occurs in about 11% of patients with sickle cell disease (SCD) before the age of 20 years, with a peak incidence between 2 years and 5 years. It usually follows the occlusion of the big vessels of the Circle of Willis, hence the usefulness of transcranial doppler (TCD) in identifying patients at risk. Guidelines call for chronic

116 Developmental Medicine & Child Neurology 2015, 57: 112–119

transfusion therapy to keep the HbS concentration at