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Título

THROMBOLYSIS IN PEDIATRIC ACUTE ISCHEMIC STROKE: TWO CASE REPORTS

Apresentação do caso

Male, 13 years old, previously diagnosed with autism spectrum disorder and epilepsy, arrived in the emergency room with acute dysarthria, lethargy and ataxia. Asymptomatic the night before, he woke up showing focal neurologic signs. At examination, he was lethargic, disoriented, dysarthric and ataxic. Head computed tomography (CT) showed signs of recent ischemic injury in both cerebellar hemispheres and hyperdensity in the basilar artery, suggestive of thrombus, confirmed by angiography. Thus, it was opted to start thrombolysis with alteplase 0,9mg/kg, with no complications and showing improvement of the symptoms during the infusion. Further investigation found patent foramen ovale (PFO) by transesophageal echocardiography. Cardiologic evaluation suggested there was a possible benefit in performing percutaneous PFO closure. At the time of discharge, the patient maintained only a discrete wide-based gait, and was using rivaroxaban.

Female, 11 years old, obese, presented with an acute case of complete left-sided hemiparesis and dysarthria. She was taken to the emergency room, where her head CT showed no abnormalities, but due to the highly suggestive acute ischemic stroke (AIS) presentation, she started thrombolysis with alteplase 0,9mg/kg, 3 hours after symptom onset. The next morning, she showed partial improvement of the motor signs. Head CT was repeated and, this time, it showed hypodensity in the right internal capsule. After 24 hours, secondary prophylaxis with AAS and simvastatin was started, as well as deep venous thrombosis prophylaxis with subcutaneous heparin. No etiology was found for the event. Patient was discharged with slurred speech and brachial predominance of complete left-sided hemiparesis.

Discussão

Pediatric AIS can be a multifactorial disease, and all patients must undergo comprehensive investigation. Thrombolysis should be considered, especially due to the benefits shown in adults. Case reports support the use of alteplase in patients aged 13 years or older, but some centers use it in younger patients with satisfactory results.

Comentários finais

Thrombolysis can be the treatment of choice in pediatric AIS, despite the lack of clinical trials in this population.

Referências (se houver)

FERRIERO, D.M. et al. Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke, [s. l.], v. 50, ed. 3, p. 51-96, 2019.

Declaração de conflito de interesses de TODOS os autores

The authors have no conflicts of interest to declare.