Case studySafe use of alteplase in a 10 months old infant with cardio-embolic stroke
Introduction
Although rare, arterial ischaemic stroke (AIS) in childhood represents an important cause of morbidity. At least 50% of patients are left with a life-long disability.1, 2, 3 The aetiology of AIS in children differs largely from that in adults. The common causes of paediatric AIS are cardiac disorders, arteriopathies, arterial dissection, haematological disorders, metabolic disorders, and infections.1, 4, 5 Multiple risk factors may be involved in the pathogenesis of AIS in children. A risk factor can be identified in 90% of the cases, whereas 52% of children with AIS have more than 1 risk factor.3, 4, 5
Such variability in pathogenesis in addition to the maturation of the coagulation system is the main reason why thrombolysis with alteplase (rtPA), which is well accepted for adult AIS, is not implemented in paediatric stroke patients. According to the 2008 guidelines for the management of childhood stroke, because of the lack of data on the safety and efficacy, thrombolysis is recommended only for clinical trials.6, 7
Successful use of rtPA in paediatric AIS has been reported several times since 2000.8 The IPSS group has reported 15 paediatric AIS patients out of 687 children (2%) who received alteplase between 2003 and 2007.9 In the same year, a Swiss group published 2 additional cases and reviewed 15 cases from previously published literature.10 Intracranial haemorrhage after alteplase treatment occurred in 4 patients from the IPSS cohort and in 2 of the 17 patients in the Swiss group, all of whom were asymptomatic.9, 10
The age of the paediatric patients who were treated with alteplase ranged from 2 to 17 years. Only 1 patient in the IPSS group was younger than 1 year and had a stroke during cardiac surgery.9 We report a case of rtPA use in a 10-month-old male infant with cardio-embolic stroke.
Section snippets
Case study
The 10-month-old patient was found to have hypoplastic left heart syndrome during the early neonatal period. A Norwood procedure with a Sano shunt was performed 13 days after birth, followed by bidirectional cavopulmonary anastomosis at the age of 3 months. He had been receiving aspirin at a dose 5 mg/kg of body weight. His clinical course was uneventful until the age of 9 months, when he became pale, tachypnoeic, and refused to eat within a week. Echocardiography revealed a severely dilated,
Discussion
Until recently, randomised clinical trials to investigate safety and efficacy of rtPA treatment had excluded children and adolescents mainly because of diverse aetiologies of AIS. Because arterial vasculitis or vasculopathy was the reported cause in nearly two-thirds of paediatric AIS cases,4, 5, 6, 7 a higher risk of bleeding complications might be expected. In addition to different stroke aetiology, age-related differences in the coagulation and fibrinolytic systems might affect the
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