Related Experiment Video
Updated: Oct 22, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Endovascular and thrombolytic treatment eligibility in childhood arterial ischemic stroke
Melissa L Hutchinson1, Lauren A Beslow2, Evelyn K Shih2
1Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, PA, USA; Departments of Neurology and Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.
Insights
Hyperacute therapy for pediatric acute ischemic stroke (AIS) is underutilized due to presentation delays, mild symptoms, contraindications, and lack of vessel occlusion. Improving these factors is crucial for increasing treatment rates in children with AIS.
Area of Science:
- Pediatric Neurology
- Stroke Medicine
- Emergency Medicine
Background:
- Acute ischemic stroke (AIS) in children is a rare but serious condition.
- Hyperacute therapies aim to restore blood flow and minimize brain damage.
- Established institutional pathways are critical for timely stroke treatment.
Purpose of the Study:
- To evaluate factors influencing hyperacute therapy eligibility and utilization in children with AIS.
- To assess the effectiveness of an institutional acute stroke treatment pathway implemented in 2005.
Main Methods:
- Retrospective analysis of a prospectively enrolled single-center cohort of children (2 to <18 years) with AIS from 2005-2017.
- Descriptive statistics used to summarize clinical data, presentation details, and Pediatric NIH Stroke Scale (PedNIHSS) scores.
- Eligibility and therapy administration assessed based on the institutional stroke pathway at presentation.
Main Results:
- Only 6% (5/90) of children with AIS received hyperacute therapy (intravenous tissue plasminogen activator [IV-tPA] and/or endovascular therapy [EVT]).
- Among those presenting within 4.5 hours, only 6 met criteria for IV-tPA (PedNIHSS ≥6, no contraindications, vessel occlusion).
- Among eligible children presenting within 6 hours after EVT availability, 43% had large vessel occlusion, but only 2 received EVT.
Conclusions:
- Low rates of hyperacute therapy utilization in pediatric AIS are attributed to delayed presentation and diagnosis.
- Mild neurologic deficits, medical contraindications to IV-tPA, and absence of vessel occlusion on imaging are significant barriers.
- Optimizing stroke pathways and addressing these contributing factors are essential to improve treatment rates in children.
Aim:
To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke treatment pathway in 2005.
Methods:
A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 - <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway.
Results:
Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5 h of time last seen well, 6 had PedNIHSS scores 6-24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6 h of time last seen well with a PedNIHSS score 6-24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6 h from time last seen well.
Conclusions:
Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.
Related Concept Videos
01:29Venous Thrombosis III: Interprofessional Care
01:29Pulmonary Embolism II: Diagnostic Studies and Interprofessional Care