DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY

COMMENTARY

Thrombolytics for acute stroke in children: eligibility, practice variability, and pediatric stroke centers LORI C JORDAN Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA. doi: 10.1111/dmcn.12604 This commentary is on the original article by Marecos et al. To view this paper visit http:/dx.doi.org/10.1111/dmcn.12588.

Thrombolysis improves outcome in adults with stroke; healthcare providers are hopeful that children may also benefit, though there are no completed studies that show safety and efficacy for patients less than 18 years of age. Marecos et al. audited charts of children with acute and non-acute arterial ischemic stroke (AIS) seen at their quaternary pediatric medical center (no emergency department or adult stroke unit, but serves as a national referral center for pediatric cerebrovascular disease) to assess which children would have been eligible for thrombolytic therapy.1 The authors also defined their local criteria for stroke thrombolysis in children and looked for barriers to thrombolytic use. Of 107 children with acute AIS, they found that none would have qualified for thrombolytic therapy based on their criteria, though three (2.8%) would have qualified if diagnosis and transfer had been timely. The authors determined that they would give tissue plasminogen activator (tPA) to children less 8 years old arriving within 6 hours of stroke onset. They also state that they would require a pediatric National Institutes of Health Stroke Scale (PedNIHSS)2 of 10 or greater. A PedNIHSS was not scored prospectively or retrospectively for these children. Controversial issues in this report include the age group, time-window, and stroke severity as measured by the PedNIHSS. The Thrombolysis in Pediatric Stroke (TIPS) trial, a safety and dose-finding study for tPA, included children aged 2 to 17 years old but was closed for low enrollment.3 If we reassess age in the current 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.

REFERENCES 1. Marecos C, Gunny R, Robinson R, Ganesan V. Are children with acute arterial ischemic stroke eligible for hyperacute thrombolysis? A retrospective audit from a tertiary UK centre. Dev Med Child Neurol doi: 10.1111/dmcn.12588. 2. Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health

© 2014 Mac Keith Press

Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42: 613–7.

Reasons why few patients with acute stroke receive tissue

3. Amlie-Lefond C. Thrombolysis in Pediatric Stroke Trial (TIPS).

ClinicalTrials.gov.

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

http://clinicaltrials.gov/ct2/

plasminogen activator. Arch Neurol 2006; 63: 661–4. 5. Bernard TJ, Rivkin MJ, Scholz K, et al. Emergence of the

show/NCT01591096?term=thrombolysis+in+pediat-

primary pediatric stroke center: impact of the Thrombolysis

ric+stroke&rank=1 (accessed 19 August 2014).

in Pediatric Stroke (TIPS) Trial. Stroke 2014; 7: 2018–23.

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Thrombolytics for acute stroke in children: eligibility, practice variability, and pediatric stroke centers.

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