The prospects and predicaments of intravenous rt-PA in childhood ischemic stroke

Abstract

One of the biggest conundrums in acute treatment of childhood arterial ischemic stroke is administration of intravenous recombinant tissue plasminogen activator. Although the benefit of this treatment is well-established in adults, the same effectiveness in children has not been demonstrated. Diversity of underlying causes of ischemic stroke in children and delay and uncertainty in diagnosis are some of the complexities that make intravenous thrombolysis elusive in this population. Physiological, pharmacological and developmental factors may also play roles in variable effect of intravenous recombinant tissue plasminogen activator in children. Current studies are aimed to determine the safety and efficacy of intravenous thrombolysis in carefully-selected children who would benefit the most from this procedure.

Keywords::

• acute stroke
• ischemic stroke
• stroke in children
• thrombolysis
• tissue plasminogen activator

Financial & competing interests disclosure

R Behrouz has received an educational grant from Genentech Inc and serves on the editorial board of BMC Neurology. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Arterial ischemic stroke (IS) in children is rare, but has a major impact both on the individual and on the society.

• Pathophysiological mechanisms of IS in children are very diverse and differ greatly from those of adults.

• There is often a delay in recognition and/or diagnosis of IS in children.

• Although the beneficial role of intravenous thrombolysis in adult IS is clear, the same does not apply to children.

• Many factors influence the efficacy of intravenous thrombolytics in children that may be physiological, pharmacological and developmental.

• The effectiveness of intravenous thrombolysis in children largely depends upon the presence of a target clot.

• A large-scale study is ongoing in which children who are thought to benefit the most from intravenous thrombolysis are carefully selected according to brain and vascular imaging.