A case of stroke thrombolysis in a child in a district general hospital

Abstract

A 15-year old schoolboy, known to suffer with epilepsy and learning difficulties was taken to A & E following a collapse at school which occurred while he was changing his clothes. The initial paediatric team assessment triggered stroke physician review and he was found to have right-sided hemiparesis and hemianopia with expressive aphasia; NIHSS was 19. An urgent CT head showed signs of early infarction in the Left Middle Cerebral Artery (LMCA) Territory. The decision to thrombolyse was made by stroke physicians across the three hospitals in the Trust, who were assessing and monitoring the situation in real time with the assistance of Telemedicine. Thrombolysis was commenced 4.5 h after the onset of symptoms with Alteplase, 0.9 mg/kg over one hour. Standard Adult Thrombolysis protocol monitoring was followed on a paediatric ward. The next day his power was 4/5 and he could mobilise; NIHSS 9. He was transferred to a specialist neurological centre. MRI confirmed a large LMCA infarct without haemorrhagic transformation. Despite extensive high signal change on MRI, neurological deficits improved, suggesting that an ischaemic penumbra had been reperfused with thrombolysis. Echocardiography showed a small patent foramen ovale and he had transcatheter closure. At 2-month follow-up his neurological examination was normal and modified rankin score, 0. Current guidelines advocate the use of thrombolysis in children only as part of a clinical trial. However, a study from the USA found that 1.6% of children with ischaemic arterial strokes were being thrombolysed. This case demonstrates safe administration of thrombolysis in children with stroke.