Researchers at the Massachusetts General Hospital, Boston, MA studied retrospectively the risk factors and yield of diagnostic tests, neuroimaging findings, and treatment of ischemic strokes in 215 consecutive young adult patients (aged 18 to 45 years) seen between 2005 and 2010. Hypertension was recorded in 20%, diabetes mellitus in 11%, dyslipidemia in 38%, and smoking in 34%. Cerebral angiography abnormalities were relevant in 67%, cardiac ultrasonography was abnormal in 50%, Holter monitoring in 1%, and hypercoagulable panel in 16%. Multiple infarcts observed in 31% were more prevalent in <35 year-olds. Arterial lesions occurred in the middle cerebral artery in 23%, internal carotid in 13%, and vertebrobasilar arteries 13%. Cardioembolic stroke occurred in 47%, including 17% with patent foramen ovale. Outcome was good in 81% at discharge. Of 29 patients receiving short-term thrombolysis, 55% had a good outcome at hospital discharge, and none had symptomatic brain hemorrhage. [1]

COMMENT. Advances in thrombolysis are discussed in the 2012 Stroke Roundup [2]. Based on the Safe Implementation of Treatments in Stroke registries, the Virtual International Stroke Trials Archive, and the US FDA, age alone is not a barrier to thrombolysis with alteplase in adults, but patients over 80 years of age are excluded by European Regulatory Authorities. The Third International Stroke Trial revealed a significantly greater treatment effect of alteplase in patients over 80 years of age than in those aged 80 or younger. Alteplase treatment within 6 hours of stroke onset improved functional outcome. A risk of symptomatic intracerebral hemorrhage with alteplase is a deterrent to more frequent use, but further studies are indicated, especially in younger patients.

A PubMed search of the literature uncovers several single case reports of the successful use of thrombolysis in the treatment of childhood stroke [3]. Coordination of neurology, critical care, and interventional radiology is recommended in management of ischemic stroke in children.

Currently, there are two treatment guidelines for therapy of childhood AIS (Royal College of Physicians in the UK, and American Heart Association and American College of Chest Physicians). Antithrombotic strategies are advocated, but the choice of agent varies with the guideline preference and risk factors. Thrombolytic treatment is not advocated [4]. In a multicenter, observational, cohort study, alteplase was used infrequently and the outcome was often poor; intracranial hemorrhage occurred in 4 of 15 patients [5]. Clinical trials are needed to determine optimal dose of alteplase in childhood stroke.