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Use and In-Hospital Outcomes of Recombinant Tissue Plasminogen Activator in Pediatric Arterial Ischemic Stroke Patients

      Background

      Outcomes in pediatric stroke are poorly understood. We sought to determine trends in the use of recombinant tissue plasminogen activator (rt-PA), treatment outcomes, and predictors of mortality for pediatric patients with acute ischemic stroke by using the Nationwide Inpatient Sample.

      Methods

      Using Nationwide Inpatient Sample data from 2001 to 2010, we identified pediatric patients (age 30 days to 18 years) with the primary diagnosis of arterial ischemic stroke. We studied trends of use of intravenous rt-PA and outcomes after thrombolysis. We also analyzed the associations of demographic factors, comorbidities, and complications of arterial ischemic stroke with in-hospital mortality.

      Results

      This study included 7044 patients. In-hospital mortality was 4.7%. The comorbidities associated with the greatest rates of in-hospital mortality were mitochondrial disorders (19.5%, P < 0.0001) and hypercoagulable states (11.4%, P < 0.0001). The main complications associated with increased mortality were intracerebral hemorrhage (19.9%, P < 0.0001), sepsis (13.2%, P < 0.0001), and pneumonia (9.3%, P = 0.0007). The rate of rt-PA use was 1.4% (99 patients). rt-PA use increased from 0.9% of patients in 2001-2005 to 2.0% in 2006-2010 (P < 0.0001). Among patients who received rt-PA, the rate of intracerebral hemorrhage was low and without fatalities; however, there was an increased discharge-to-long-term-facilities rate in the rt-PA group (50.8% versus 12.1%, P < 0.0001).

      Conclusion

      Arterial ischemic stroke in the pediatric population is associated with a greater rate of mortality when related to mitochondrial diseases or hypercoagulability. rt-PA use is increasing in pediatric patients with arterial ischemic stroke. Pediatric patients receiving rt-PA have a low risk of fatal hemorrhage. Although patients receiving rt-PA have a morbidity rate, these individuals may have a worse stroke severity.

      Keywords

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      References

        • Christerson S.
        • Stromberg B.
        Childhood stroke in Sweden I: incidence, symptoms, risk factors and short-term outcome.
        Acta Paediatr. 2010; 99: 1641-1649
        • Gandhi S.K.
        • McKinney J.S.
        • Sedjro J.E.
        • Cosgrove N.M.
        • Cabrera J.
        • Kostis J.B.
        Temporal trends in incidence and long-term case fatality of stroke among children from 1994 to 2007.
        Neurology. 2012; 78: 1923-1929
        • Roach E.S.
        • Golomb M.R.
        • Adams R.
        • et al.
        Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young.
        Stroke. 2008; 39: 2644-2691
        • Goldstein L.B.
        • Bushnell C.D.
        • Adams R.J.
        • et al.
        Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2011; 42: 517-584
        • Monagle P.
        • Chalmers E.
        • Chan A.
        • et al.
        Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).
        Chest. 2008; 133: 887S-968S
        • Monagle P.
        • Chan A.K.
        • Goldenberg N.A.
        • et al.
        Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
        Chest. 2012; 141: e737S-801S
        • Lehman L.L.
        • Kleindorfer D.O.
        • Khoury J.C.
        • et al.
        Potential eligibility for recombinant tissue plasminogen activator therapy in children: a population-based study.
        J Child Neurol. 2011; 26: 1121-1125
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Mackay M.T.
        • Wiznitzer M.
        • Benedict S.L.
        • Lee K.J.
        • Deveber G.A.
        • Ganesan V.
        Arterial ischemic stroke risk factors: the International Pediatric Stroke Study.
        Ann Neurol. 2011; 69: 130-140
        • Ganesan V.
        • Prengler M.
        • McShane M.A.
        • Wade A.M.
        • Kirkham F.J.
        Investigation of risk factors in children with arterial ischemic stroke.
        Ann Neurol. 2003; 53: 167-173
        • Williams L.S.
        • Garg B.P.
        • Cohen M.
        • Fleck J.D.
        • Biller J.
        Subtypes of ischemic stroke in children and young adults.
        Neurology. 1997; 49: 1541-1545
        • Sun D.
        • Wu X.M.
        • Wang Z.W.
        • et al.
        A single-site retrospective study of pediatric arterial ischemic stroke etiology, clinical presentation, and radiologic features.
        Chin Med J (Engl). 2013; 126: 3446-3450
        • Golomb M.R.
        • Fullerton H.J.
        • Nowak-Gottl U.
        • Deveber G.
        Male predominance in childhood ischemic stroke: findings from the international pediatric stroke study.
        Stroke. 2009; 40: 52-57
        • Lenicek Krleza J.
        • Duranovic V.
        • Lujic L.
        • et al.
        The burden of paediatric stroke and cerebrovascular disorders in Croatia.
        Int J Stroke. 2009; 4: 390-394
        • Lo W.
        • Stephens J.
        • Fernandez S.
        Pediatric stroke in the United States and the impact of risk factors.
        J Child Neurol. 2009; 24: 194-203
        • Lynch J.K.
        • Hirtz D.G.
        • DeVeber G.
        • Nelson K.B.
        Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke.
        Pediatrics. 2002; 109: 116-123
        • Janjua N.
        • Nasar A.
        • Lynch J.K.
        • Qureshi A.I.
        Thrombolysis for ischemic stroke in children: data from the nationwide inpatient sample.
        Stroke. 2007; 38: 1850-1854
        • Lynch J.K.
        • Han C.J.
        Pediatric stroke: what do we know and what do we need to know?.
        Semin Neurol. 2005; 25: 410-423
        • Goldenberg N.A.
        • Bernard T.J.
        • Fullerton H.J.
        • Gordon A.
        • deVeber G.
        Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study.
        Lancet Neurol. 2009; 8: 1120-1127
        • Lyle C.A.
        • Bernard T.J.
        • Goldenberg N.A.
        Childhood arterial ischemic stroke: a review of etiologies, antithrombotic treatments, prognostic factors, and priorities for future research.
        Semin Thromb Hemost. 2011; 37: 786-793
        • Rodan L.
        • McCrindle B.W.
        • Manlhiot C.
        • et al.
        Stroke recurrence in children with congenital heart disease.
        Ann Neurol. 2012; 72: 103-111
        • Amlie-Lefond C.
        • deVeber G.
        • Chan A.K.
        • et al.
        Use of alteplase in childhood arterial ischaemic stroke: a multicentre, observational, cohort study.
        Lancet Neurol. 2009; 8: 530-536
        • Benesch C.
        • Witter Jr., D.M.
        • Wilder A.L.
        • Duncan P.W.
        • Samsa G.P.
        • Matchar D.B.
        Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease.
        Neurology. 1997; 49: 660-664
        • Golomb M.R.
        • Garg B.P.
        • Saha C.
        • Williams L.S.
        Accuracy and yield of ICD-9 codes for identifying children with ischemic stroke.
        Neurology. 2006; 67: 2053-2055
        • Qureshi A.I.
        • Harris-Lane P.
        • Siddiqi F.
        • Kirmani J.F.
        International classification of diseases and current procedural terminology codes underestimated thrombolytic use for ischemic stroke.
        J Clin Epidemiol. 2006; 59: 856-858