Letter by Diplomatico and Barbi Regarding Article, "Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association".

To the Editor: We appreciated the article by Ferriero et al on the management of stroke in neonates and children. The authors perform an overview of the causes of pediatric stroke and try to produce an omni-comprehensive guideline for treatment. However, we suggest that the part dealing with the hyperacute treatment of acute ischemic stroke in childhood could have been more detailed. As a matter of fact, when dealing with rare conditions with very limited available controlled studies, case series could be useful and should be included in the available evidence. As the authors report the thrombus composition and the fibrin clot structure in pediatric age is weaker than the adult one, because of significantly larger pore size, with a higher chance of recanalization, despite a higher plasminogen activator inhibitor function. Notwithstanding this consideration, Ferriero et al suggest using intravenous tPA (tissue-type plasminogen activator) in children at the adult dosage of 0.9 mg/ kg, considering it as a conservative dose and hypothesizing a higher effective dose, as reported also by others in literature, even in the absence of any conclusive evidence. We highlight that the authors failed to mention some studies concerning low-dose tPA thrombolysis (0.6 mg/kg), as the Japanese protocol, that appears to be more safe and equally effective for thrombolysis of pediatric acute ischemic stroke. We think that in front of the lack of conclusive trials and considering clinicians’ caution in using poorly codified treatments, the option of a lower dose, equally effective, and potentially safer, should have been discussed and considered in the review. Disclosures None.