Thrombolysis in Pediatric Versus Adult Ischemic Stroke – Closing the Clinical Knowledge Gap

Andrea Eberly, MD, MS, FAAEMBedside Diagnostic Challenge, Emergency Medicine, Family Medicine, Guideline Knowledge Check, Internal Medicine, Nurse Practitioner, Pediatric Emergency Medicine, Pediatric Medicine, Physician Assistant, Urgent Care

Thrombolysis in Stroke - Thrombolysis inPediatric Versus Adult Ischemic Stroke Patient Case Q&A - Closing the Clinical Knowledge Gap

Thrombolysis in Stroke: Thrombolysis in Pediatric vs Adult Ischemic Stroke - Closing Clinical Knowledge Gaps

Andrea Eberly, MD, MS, FAAEM examines the differences between thrombolysis in pediatric vs. adult ischemic stroke.

In 2019, the American Heart Association (AHA) published updated adult and pediatric ischemic stroke guidelines. In what important ways are pediatric eligibility criteria for thrombolysis similar to/different from those for adults?

Try this case and test your knowledge of thrombolysis in pediatric versus adult ischemic stroke.

A 7-year-old girl with a history of sickle cell disease presents to the emergency department (ED) with her parents after a multi-hour drive to the next large hospital from their rural home.

The parents state that about 4 hours ago, their daughter was suddenly drooling and not responding normally while the family was watching TV.

She was also unable to move the left side of her body.

The parents also state that the patient has had a febrile illness with nausea, vomiting, and diarrhea for the last 3 days.

Her vital signs are:

  • heart rate 105 beats/minute
  • blood pressure 95/70 mm Hg
  • respiratory rate 18 breaths/minute
  • temperature 100.5 °F (38.1 °C)
  • 98% pulse oximetry on room air

Examination reveals a somnolent, thin child who appears dehydrated.

Her neurological exam is consistent with a possible right-sided stroke in the distribution of a major cerebral artery.

During the exam, she has a brief, self-limited seizure. 

Question:

Under what circumstances would this patient be eligible for thrombolysis with alteplase (TPA) if her workup is negative for a stroke mimic?

Answer Options:

Different from adults, children are eligible for TPA for up to 6 hours after the known onset time of a stroke.

Different from adults, a negative plain head CT is not sufficient to initiate thrombolysis in children, even if the child meets all other TPA criteria.

In both adults and children, seizures and hematologic disorders are exclusion criteria from thrombolysis.

In both adults and children, a National Institute for Health Stroke Scale (NIHSS) score > 25 is an exclusion criterion for TPA (risk of thrombolysis outweighs the benefits).

See the Answer:

Dr. Andrea Eberly is one of the seasoned medical experts that contribute to Med-Challenger Medical Education products for medical board certification exam preparation, maintenance of medical certification, and continuing medical education requirements. 

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