Thrombolysis in Pediatric Stroke (TIPS)

To be eligible for TIPS, a patient must meet the following Inclusion Criteria:

1. Age 2 to 17 years inclusive.
2. Clinical presentation consisting of clearly defined acute onset of neurological deficit in a pattern consistent with arterial territory ischemia.
3. Clinically significant deficit as defined by a PedNIHSS score of ≥ 6 and ≤ 24 felt to be due to acute stroke that is not improving at the time of initiation of tPA administration
4. Time of symptom onset within 4.5 hours of initiation of treatment for IV tPA. Time of symptom onset is defined as time the patient was last seen awake and at neurological baseline.
5. Radiological confirmation of an acute arterial ischemic stroke in one of two ways:

• MRI confirmation, consisting of acute infarction with restricted diffusion in an arterial territory consistent with the clinical syndrome plus MRA showing partial or complete occlusion in an intracranial artery corresponding to the infarct location, OR,
• CT and CT angiogram confirmation, consisting of normal head CT or early hypodensity in an arterial territory consistent with the clinical syndrome plus CT angiogram showing partial or complete occlusion in an intracranial artery corresponding to the infarct location.

1. Baseline neuroimaging (CT or MRI) with no evidence of intracranial hemorrhage (including HI-1, HI-2, PH-1 or PH-2). If no head CT scan is done, the pre-tPA MRI must include Gradient-recalled ECHO (GRE) imaging or Susceptibility Weighted Imaging (SWI) sequences.
2. Children with seizures at or following onset of stroke may be included, as long as the clinical picture is consistent with the documented arterial occlusion.

3.4.1.2.2. Patients with the following Exclusion Criteria will not be eligible for TIPS:

Safety Related exclusion criteria:

1. Patients in whom time of symptom onset is unknown.
2. Pregnancy
3. Clinical presentation suggestive of subarachnoid hemorrhage (SAH), even if head CT or head MRI scan is negative for blood.
4. Patient who would decline blood transfusion if indicated
5. History of prior intracranial hemorrhage
6. Known cerebral arterial venous malformation, aneurysm, or neoplasm
7. Persistent Systolic Blood Pressure > 15% above the 95th percentile for age while sitting or supine
8. Glucose < 50 mg/dl (2.78 mmol/l) or > 400 mg/dl (22.22 mmol/l)
9. Bleeding diathesis including platelets < 100,000, PT > 15 sec (INR > 1.4) or elevated PTT > upper limits of the normal range.
10. Clinical presentation consistent with acute myocardial infarction (MI) or post-MI pericarditis that requires evaluation by cardiology prior to treatment
11. Stroke, major head trauma, or intracranial surgery within the past 3 months
12. Major surgery or parenchymal biopsy within 10 days (relative contraindication)
13. Gastrointestinal or urinary bleeding within 21 days (relative contraindication)
14. Arterial puncture at noncompressible site or lumbar puncture within 7 days (relative contraindication). Patients who have had a cardiac catheterization via a compressible artery are not excluded.
15. Patient with malignancy or within 1 month of completion of treatment for cancer
16. Patients with an underlying significant bleeding disorder. Patients with a mild platelet dysfunction, mild von Willebrand Disease or other mild bleeding disorders are not excluded.

Stroke related exclusions:

1. Mild deficit (PedNIHSS < 6) at start of tPA infusion
2. Severe deficit suggesting very large territory stroke, with pre-tPA PedNIHSS > 25, regardless of the infarct volume seen on neuroimaging
3. Stroke suspected to be due to subacute bacterial endocarditis, moyamoya, sickle cell disease, meningitis, bone marrow, air or fat embolism
4. Previously diagnosed primary angiitis of the central nervous system (PACNS) or secondary CNS vasculitis. Focal cerebral arteriopathy (FCA) of childhood is not a contraindication.

Neuro-imaging related exclusions:

1. Intracranial hemorrhage (HI-1, HI-2, PH-1 or PH-2) on pretreatment head MRI or head CT
2. Intracranial dissection (defined as at or distal to the opthalmic artery)
3. Large infarct volume, defined by the finding of acute infarct on MRI involving 1/3 or or more of the complete MCA territory involvement, regardless of the pre-tPA PedNIHSS score due to increased risk of ICH.78, 79

Drug Related exclusions:

1. Known allergy to recombinant tissue plasminogen activator
2. Patient on anticoagulation therapy must have INR ≤ 1.4
3. Patient who received heparin within 4 hours must have aPTT in normal range
4. LMWH within past 24 hours (aPTT and INR will not reflect LMWH effect)