As promised, here’s some follow-up from Dr. Edelman’s excellent talk today.
First, here is a nice review of perinatal stroke. They emphasize the importance of the newborn’s immature coagulation system and his recent attachment to the placenta, which has unique hemostatic mechanisms.
Regarding age-related differential stroke mechanisms, here is a prospective study of children aged 1 month to 18 years with arterial and venous strokes. The study enrolled 676 children with arterial events across 10 countries, giving them a good denominator from which to tease out age-related risk factors, along with geographic and other differences:
- Arteriopathies (transient cerebral arteriopathy, moyamoya disease, dissection, vasculitis, sickle cell arteriopathy, and post-varicella arteriopathy) were most common in 5-9 year-olds.
- “Acute systemic conditions” (fever > 48 hours, sepsis, shock, dehydration, acidosis, and anoxia) were more common in younger children.
- “Chronic head and neck disorders” (migraine, tumors, VP shunts, aneurysms, MELAS, and AVMs) were more common in older children.
Finally, you all know that our stroke section strongly supports the use of clinical practice guidelines as a starting point when questioning how to treat patients. Here’s an American Heart Association Scientific Statement on Management of Stroke in Infants and Children; it’s a great resource for those interested in neonatal and pediatric stroke. Regarding Ahsan’s specific question of tPA use in these populations, they write:
Thrombolytic agents are not recommended in neonates until more information about the safety and effectiveness of these agents is known (Class III, Level of Evidence C).
Until there are additional published safety and efficacy data, tPA generally is not recommended for children with AIS outside a clinical trial (Class III, Level of Evidence C). However, there was no consensus about the use of tPA in older adolescents who otherwise meet standard adult tPA eligibility criteria.