Can we use thrombolytic therapy (tissue plasminogen activator, tPA) in a 2-year-old patient with facial droop and slurred speech who presented 30 minutes after incident if the computed tomography angiogram (CTA) shows no vessel obstruction?

Thrombolytic Therapy Should NOT Be Used in This 2-Year-Old Patient

Thrombolytic therapy with tPA is generally not recommended for children with acute ischemic stroke outside of a clinical trial, and the absence of vessel obstruction on CTA further eliminates any potential indication for thrombolysis. 1

Primary Contraindication: Pediatric Age and Lack of Safety Data

The American Heart Association Stroke Council explicitly states that tPA cannot be endorsed for children with acute ischemic stroke except in the context of a clinical trial (Class III recommendation) due to insufficient safety and efficacy data. 1

Key evidence against pediatric thrombolysis includes:

• High complication rates: In systemic thromboses, 40% of children treated with tPA experienced major complications and 30% had minor complications, despite achieving clot dissolution in 85% of cases. 1

• Unproven benefit: Analysis of 46 pediatric patients <18 years who received tPA between 2000-2003 concluded that safety and efficacy could not be determined. 1

• Hemorrhagic risk: Delayed administration likely leads to unacceptable rates of intracerebral hemorrhage in children, similar to adults. 1

Critical Imaging Finding: No Vessel Obstruction

The absence of vessel obstruction on CTA is a fundamental contraindication to thrombolytic therapy. 1

Thrombolysis requires demonstration of:

• Arterial occlusion: Vascular imaging (CTA, MRA, or conventional angiography) is essential before considering thrombolysis, particularly beyond the 3-hour window. 1, 2

• Target for intervention: Without documented vessel occlusion, there is no thrombus to lyse, eliminating any theoretical benefit while maintaining all hemorrhagic risks. 1

• Alternative diagnosis: The absence of vessel obstruction in a child with stroke-like symptoms should prompt consideration of stroke mimics (postictal paralysis, complicated migraine, or other non-thrombotic etiologies). 1

Appropriate Management Algorithm

For this 2-year-old patient presenting within 30 minutes with no vessel obstruction:

1. Complete emergent imaging evaluation: MRI with diffusion-weighted imaging (DWI) is superior to CT for detecting acute ischemic infarction in children (77% vs 16% sensitivity in first 3 hours) and can identify stroke mimics. 1

2. Supportive care: Maintain adequate tissue oxygenation, monitor airway protection, and ensure hemodynamic stability. 1

3. Investigate underlying etiology: Evaluate for cardiac sources, vasculopathy, prothrombotic conditions, and other pediatric stroke risk factors. 1

4. Consider antiplatelet therapy: Aspirin at 3-5 mg/kg per day is reasonable for stroke prevention in children (Class IIa recommendation), though timing after acute presentation should be individualized. 1

Common Pitfalls to Avoid

• Extrapolating adult guidelines to children: The 3-hour window and standard tPA protocols used in adults have not been validated in pediatric populations. 1

• Treating without vessel imaging: Even in adults within the therapeutic window, vascular imaging showing vessel occlusion is increasingly considered essential for treatment decisions. 1, 2

• Ignoring stroke mimics: Up to 44% of children enrolled in the Thrombolysis in Pediatric Stroke trial had stroke mimics rather than confirmed arterial ischemic stroke. 1

• Delayed recognition of contraindications: 22% of children in the pediatric stroke trial had medical contraindications to thrombolysis that should have been identified earlier. 1