Aspirin Versus Low-Molecular-Weight Heparin for Ischemic Stroke in Children: An Unanswered Question
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To the Editor:
We read with interest the article entitled “Aspirin Versus Low-Dose Low-Molecular-Weight Heparin: Antithrombotic Therapy in Pediatric Ischemic Stroke Patients: A Prospective Follow-Up Study.”1 As addressed by the authors, there is scant evidence to guide the treatment of children with stroke. Thus, the authors have contributed important and significant knowledge regarding the treatment of pediatric stroke. This includes valuable information on the safety and feasibility of administering aspirin or low-molecular-weight heparin (LMWH) in a large number of children with stroke. However, the design and results of the present study cannot substantiate the following conclusion: “This prospective multicenter follow-up study has provided evidence that low-dose LMWH is not superior to aspirin and vice versa in preventing recurrent stroke ….” Because the treatment was assigned by multiple treating physicians and was not prospectively standardized, it is possible that patients deemed to have an increased risk of recurrence were treated with LMWH and low-risk patients were treated with aspirin (or vice versa). Although these shortcomings are addressed in the article, they are not reflected in the conclusions.
Readers should be aware of the fact that low-dose LMWH (at “prophylactic” doses) was used in the study, as has been clearly stated by the authors. Therapeutic doses of LMWH may prevent stroke recurrence in children, as has been shown in adults with stroke,2 but without the risks of hemorrhagic complications seen in adults. This is because in children there is a lack of hypertension, atherosclerosis, and other age-related factors known to increase the risk of hemorrhagic complications. In our institutional consecutive cohort studies, 81 infants and children with arterial strokes have received therapeutic LMWH …