AntithromboticTherapyinNeonates

andChildren

AntithromboticTherapyandPreventionof
Thrombosis,9thed:AmericanCollegeof
ChestPhysiciansEvidenceBasedClinical
PracticeGuidelines

Copyright:AmericanCollegeofChestPhysicians2012

Introduction

Newresearchcontinuestodemonstratethedifferencesinthe
pharmacokinetics,doseresponses,andmonitoringtestsfor
anticoagulationtherapyinchildrencomparedwithadults.
Despitethelackofclinicaloutcomedata,wecontinueto
recommendmonitoringtospecifictargetrangesforboth
unfractionatedheparinandlowmolecularweightheparinin
neonatesandchildrenandacknowledgetheongoingneedfor
dedicatedclinicaltrialsinthisgroup.Furthermore,with
respecttoneweranticoagulantsavailableonthemarket,there
isinsufficientevidencetomakerecommendationsabouttheir
safeuseinchildrenatthistime.

AntithromboticTherapyinNeonatesandChildren

Wesuggestthatwherepossible,pediatrichematologistswith
experienceinthromboembolismmanagepediatricpatients
withthromboembolism(Grade2C).Whenthisisnotpossible,
wesuggestacombinationofaneonatologist/pediatricianand
adulthematologistsupportedbyconsultationwithan
experiencedpediatrichematologist(Grade2C).

HeparininNeonatesandChildren
Wesuggestthattherapeuticunfractionatedheparin(UFH)in
childrenistitratedtoachieveatargetrangeofantiXaactivity
of0.35to0.7units/mLoranactivatedpartialthromboplastin
timerangethatcorrelatestothisantiXarangeortoa
protaminetitrationrangeof0.2to0.4units/mL(Grade2C).We
suggestthatwheninitiatingUFHtherapy,UFHbolusesbeno
greaterthan75to100units/kgandthatbolusesbewithheldor
reducediftherearesignificantbleedingrisks(Grade2C).We
suggestavoidinglongtermuseoftherapeuticUFHinchildren
(Grade2C).

LMWHinNeonatesandChildren
Wesuggest,forneonatesandchildrenreceivingeitheronceor
twicedailytherapeuticLMWHthatthedrugbemonitoredtoa
targetantiXaactivityrangeof0.5to1.0units/mLinasample
taken4to6hafterSCinjectionor0.5to0.8units/mLina
sampletaken2to6hafterSCinjection(Grade2C).

VKAsinNeonatesandChildren
Wesuggest,forchildrenreceivingVKAs,thatthedrugbe
monitoredtoatargetINRof2.5(range,2.03.0),exceptinthe
settingofprostheticcardiacvalveswherewesuggestadherence
totheadultrecommendationsoutlinedinthearticleby
Whitlocketalinthissupplement(Grade2C).Wesuggestthat
INRmonitoringwithpointofcaremonitorsbemadeavailable
whereresourcesmakethispossible(Grade2C).

AspirininChildren
Wesuggestthatwhenaspirinisusedforantiplatelettherapyin
children,itisusedindosesof1to5mg/kgperday(Grade2C).

VTEinNeonates
Wesuggestthatcentralvenousaccessdevices(CVADs)or
umbilicalvenouscatheters(UVCs)associatedwithconfirmed
thrombosisberemovedafter3to5daysoftherapeutic
anticoagulationratherthanleftinsitu(Grade2C).

Wesuggesteitherinitialanticoagulationorsupportivecare
withradiologicmonitoringforextensionofthrombosisrather
thannofollowup(Grade2C);however,inpreviouslyuntreated
patients,werecommendthestartofanticoagulationif
extensionoccurs(Grade2C).Wesuggestthatanticoagulation
shouldbewitheither(1)LMWHor(2)UFHfollowedby
LMWH.Wesuggestatotaldurationofanticoagulationof
between6weeksand3monthsratherthanshorterorlonger
durations(Grade2C).

VTEinNeonates
IfeitheraCVADoraUVCisstillinplaceoncompletionof
therapeuticanticoagulation,wesuggestaprophylacticdoseof
anticoagulationuntilsuchtimeastheCVADorUVCis
removed(Grade2C).Wesuggestagainstthrombolytictherapy
forneonatalVTEunlessmajorvesselocclusioniscausing
criticalcompromiseoforgansorlimbs(Grade2C).Wesuggest
ifthrombolysisisrequired,tissueplasminogenactivator(tPA)
isusedratherthanotherlyticagents(Grade2C),andwe
suggestplasminogen(freshfrozenplasma)administration
priortocommencingtherapy(Grade2C).

RenalVeinThrombosisinNeonates

Forunilateralrenalveinthrombosis(RVT)intheabsenceof
renalimpairmentorextensionintotheinferiorvenacava
(IVC),wesuggesteither(1)supportivecarewithradiologic
monitoringforextensionofthrombosis(ifextensionoccurswe
suggestanticoagulation)or(2)anticoagulationwith
UFH/LMWHorLMWHintherapeuticdosesratherthanno
therapy.Ifanticoagulationisused,wesuggestatotalduration
ofbetween6weeksand3monthsratherthanshorterorlonger
durationsoftherapy(Grade2C).ForunilateralRVTthat
extendsintotheIVC,wesuggestanticoagulationwith
UFH/LMWHorLMWHforatotaldurationofbetween6
weeksand3months(Grade2C).

RenalVeinThrombosisinNeonates

ForbilateralRVTwithevidenceofrenalimpairment,we
suggestanticoagulationwithUFH/LMWHorinitial
thrombolytictherapywithtPAfollowedbyanticoagulation
withUFH/LMWH(Grade2C).

CVADProphylaxisinNeonates
ForneonateswithCVADs,werecommendtomaintainCVAD
patencywithUFHcontinuousinfusionat0.5units/kgperh
overnoprophylaxis(Grade1A)orintermittentlocal
thrombolysis(Grade2C).ForneonateswithblockedCVADs,
wesuggestlocalthrombolysisafterappropriateclinical
assessment(Grade2C).

ThromboprophylaxisforNeonatesandChildrenWithBlalockTaussigShuntsand
ModifiedBlalockTaussigShunts(MBTS)

ForneonatesandchildrenhavingmodifiedMBTS,wesuggest
intraoperativeUFHtherapy(Grade2C).Forneonatesand
childrenafterMBTSsurgery,wesuggesteitheraspirinorno
antithrombotictherapyascomparedwithprolongedLMWH
orVKAs(Grade2C).

TherapyforFemoralArteryThrombosisinNeonatesandChildren

Forneonatesandchildrenwithacutefemoralartery
thrombosis,werecommendtherapeuticdosesofIVUFHas
initialtherapycomparedwithaspirinornotherapy(Grade1B)
orLMWH(Grade2C).Wesuggestsubsequentconversionto
LMWH,orelsecontinuationofUFH,tocomplete5to7daysof
therapeuticanticoagulationascomparedwithashorteror
longerduration(Grade2C).

TherapyforFemoralArteryThrombosisinNeonatesandChildren

Forneonatesandchildrenwithlimbthreateningororgan
threatening(viaproximalextension)femoralarterythrombosis
whofailtorespondtoinitialUFHtherapyandwhohaveno
knowncontraindications,werecommendthrombolysis(Grade
1C).Forneonatesandchildrenwithfemoralarterythrombosis,
werecommendsurgicalinterventioncomparedwithUFH
therapyalonewhenthereisacontraindicationtothrombolytic
therapyandorganorlimbdeathisimminent(Grade1C).

ProphylaxisforPeripheralArterialCathetersinNeonatesandChildren

Forneonatesandchildrenwithperipheralarterialcathetersin
situ,werecommendUFHcontinuousinfusionat0.5units/mL
at1mL/hcomparedwithnormalsaline(Grade1A).

TherapyforPeripheralArteryThrombosisSecondarytoPeripheral
ArteryCathetersinNeonatesandChildren

Forneonatesandchildrenwithaperipheralarterialcatheter
relatedthromboembolism,wesuggestimmediateremovalof
thecatheter(Grade2B).Forneonatesandchildrenwitha
symptomaticperipheralarterialcatheterrelated
thromboembolism,wesuggestUFHanticoagulationwithor
withoutthrombolysisorsurgicalthrombectomyand
microvascularrepairwithsubsequentheparintherapy(Grade
2C).

ProphylaxisofUmbilicalArterialCathetersinNeonates

Forneonateswithumbilicalarterialcatheters(UACs),we
suggestUACplacementinahighratherthanalowposition
(Grade2B).

ProphylaxisofUmbilicalArterialCathetersinNeonates

For neonates with UAC, we suggest prophylaxis with a lowdose UFH infusion via the UAC (heparin concentration of 0.251 unit/mL, total heparin dose of 25-200 units/kg per day) to
maintain patency (Grade 2A) .

ProphylaxisforCardiacCatheterizationinNeonatesandChildren

Forneonatesandchildrenrequiringcardiaccatheterizationvia
anartery,werecommendadministrationofIVUFHas
thromboprophylaxisovernoprophylaxis(Grade1A)oraspirin
(Grade1B).Forneonatesandchildrenrequiringcardiac
catheterizationviaanartery,werecommendtheuseofUFH
dosesof100units/kgasaboluscomparedwitha50unit/kg
bolus(Grade1B).Inprolongedprocedures,wesuggestfurther
dosesofUFHratherthannofurthertherapy(Grade2B).

CerebralSinovenousThrombosisinNeonates

Forneonateswithcerebralsinovenousthrombosis(CSVT)
withoutsignificantintracranialhemorrhage,wesuggest
anticoagulation,initiallywithUFHorLMWHand
subsequentlywithLMWH,foratotaltherapyduration
between6weeksand3monthsratherthanshorterorlonger
treatmentduration(Grade2C).ForneonateswithCSVTwith
significanthemorrhage,wesuggesteither(1)anticoagulation
or(2)supportivecarewithradiologicmonitoringofthe
thrombosisat5to7daysandanticoagulationifthrombus
extensionisnotedascomparedwithnotherapy(Grade2C).

ArterialIschemicStrokeinNeonates
Forneonateswithafirstarterialischemicstroke(AIS),inthe
absenceofadocumented,ongoingcardioembolicsource,we
suggestsupportivecareoveranticoagulationoraspirintherapy
(Grade2C).

ArterialIschemicStrokeinNeonates
ForneonateswithafirstAISandadocumentedcardioembolic
source,wesuggestanticoagulationwithUFHorLMWH(Grade
2C).

ArterialIschemicStrokeinNeonates
ForneonateswithrecurrentAIS,wesuggestanticoagulantor
aspirintherapy(Grade2C).

NeonatesWithPurpuraFulminans
Forneonateswithclinicalpresentationsofhomozygousprotein
Cdeficiency,werecommendadministrationofeither10to20
mL/kgoffreshfrozenplasmaevery12horproteinC
concentrate,whenavailable,at20to60units/kguntilthe
clinicallesionsresolve(Grade1A).Forneonateswith
homozygousproteinCdeficiency,afterinitialstabilization,we
recommendlongtermtreatmentwithVKA(Grade1C),LMWH
(Grade1C),proteinCreplacement(Grade1B),orliver
transplantation(Grade1C)comparedwithnotherapy.

DVTandPEinChildren
InchildrenwithfirstVTE(CVADandnonCVADrelated)we
recommendacuteanticoagulanttherapywitheitherUFHor
LMWH(Grade1B).Werecommendinitialtreatmentwith
UFHorLMWHforatleast5days(Grade1B).Forongoing
therapy,werecommendLMWHorUFH.Forpatientsinwhom
clinicianswillsubsequentlyprescribeVKAs,werecommend
beginningoraltherapyasearlyasday1anddiscontinuing
UFH/LMWHonday6orlaterthanday6iftheINRhasnot
exceeded2.0comparedwithnotherapy(Grade1B).

DVTandPEinChildren
WesuggestthatchildrenwithidiopathicVTEreceive
anticoagulanttherapyfor6to12monthscomparedwithno
therapy(Grade2C).

Valuesandpreferences:Familieswhoplaceahighvalueon
avoidingtheunknownriskofrecurrenceintheabsenceofan
ongoingriskfactorandalowervalueonavoidingthe
inconvenienceoftherapyorpotentialimpactoftherapyongrowth
anddevelopmentandbleedingriskassociatedwithantithrombotic
therapyarelikelytochoosetocontinueanticoagulanttherapy
beyond6to12months.

DVTandPEinChildren
InchildrenwithsecondaryVTE(ie,VTEthathasoccurredin
associationwithaclinicalriskfactor)inwhomtheriskfactor
hasresolved,wesuggestanticoagulanttherapybeadministered
for3months(Grade2C)ascomparedwithnofurthertherapy.
Inchildrenwhohaveongoing,butpotentiallyreversiblerisk
factors,suchasactivenephroticsyndromeorongoing
asparaginasetherapy,wesuggestcontinuinganticoagulant
therapybeyond3monthsineithertherapeuticorprophylactic
dosesuntiltheriskfactorhasresolved(Grade2C).

DVTandPEinChildren
InchildrenwithrecurrentidiopathicVTE,werecommend
indefinitetreatmentwithVKAs(Grade1A).

DVTandPEinChildren
InchildrenwithrecurrentsecondaryVTEswithanexisting
reversibleriskfactorforthrombosis,wesuggest
anticoagulationuntilresolutionoftheprecipitatingfactorbut
foraminimumof3monthsascomparedwithnofurther
therapy(Grade2C).

DVTandPEinChildren
InchildrenwithaCVADinplacewhohaveaVTE,ifaCVAD
isnolongerrequiredorisnonfunctioning,werecommenditbe
removed(Grade1B).Wesuggestatleast3to5daysof
anticoagulationtherapypriortoitsremovalratherthanno
anticoagulationpriortoremoval(Grade2C).IfCVADaccessis
requiredandtheCVADisstillfunctioning,wesuggestthatthe
CVADremaininsituandthepatientgivenanticoagulants
(Grade2C).ForchildrenwithafirstCVADrelatedVTE,we
suggestinitialmanagementasforsecondaryVTEaspreviously
described.

DVTandPEinChildren
InchildrenwithCVADinplacewhohaveaVTEandinwhom
theCVADremainsnecessary,wesuggest,aftertheinitial3
monthsoftherapy,thatprophylacticdosesofVKAs(INR
range,1.51.9)orLMWH(antiXalevelrange,0.10.3
units/mL)begivenuntiltheCVADisremoved(Grade2C).If
recurrentthrombosisoccurswhilethepatientisreceiving
prophylactictherapy,wesuggestcontinuingtherapeuticdoses
untiltheCVADisremovedandforaminimumof3months
followingtheVTE(Grade2C).

ThrombolysisinPediatricPatientsWithDVT
InchildrenwithVTE,wesuggestthatthrombolysistherapybe
usedonlyforlifeorlimbthreateningthrombosis(Grade2C).
Ifthrombolysisisusedinthepresenceofphysiologicallylow
levelsorpathologicdeficienciesofplasminogen,wesuggest
supplementationwithplasminogen(Grade2C).Inchildrenwith
VTEinwhomthrombolysisisused,wesuggestsystemic
thrombolysisorcatheterdirectedthrombolysis,dependingon
institutionalexperienceand,inthelattercase,technical
feasibility.

ThrombectomyandIVCFilterUseinPediatricPatientsWithDVT

InchildrenwithlifethreateningVTE,wesuggest
thrombectomy(Grade2C).Inchildrenwhohavehada
thrombectomy,wesuggestanticoagulanttherapyasper
recommendation(2.22)(Grade2C).Inchildren>10kgbody
weightwithlowerextremityVTEandacontraindicationto
anticoagulation,wesuggestplacementofaretrievableIVC
filter(Grade2C).Inchildrenwhoreceiveafilter,wesuggest
thatthefilterberemovedassoonaspossibleifthrombosisis
notpresentinthebasketofthefilterandwhen
contraindicationtoanticoagulationisresolved(Grade2C).In
childrenwhoreceiveanIVCfilter,werecommendappropriate
anticoagulationforVTE(see1.2)assoonasthe
contraindicationtoanticoagulationisresolved(Grade1C).

DVTinChildrenWithCancer
Inchildrenwithcancer,wesuggestthatmanagementofVTE
followthegeneralrecommendationsformanagementofVTE
inchildren.WesuggesttheuseofLMWHinthetreatmentof
VTEforaminimumof3monthsuntiltheprecipitatingfactor
hasresolved(eg,useofasparaginase)(Grade2C).
Remarks:Thepresenceofcancer,theneedforsurgery,
chemotherapy,orothertreatmentsmaymodifytheriskbenefit
ratiofortreatmentofVTE,andcliniciansshouldconsiderthese
factorsonanindividualbasis.

ChildrenWithAPLAsandDVT
ForchildrenwithVTEinthesettingofantiphospholipid
antibodies(APLAs),wesuggestmanagementaspergeneral
recommendationsforVTEmanagementinchildren.

ChildrenWithAPLAsandDVT
ForchildrenwithVTE,independentofthepresenceorabsence
ofinheritedthrombophilicriskfactors,wesuggestthatthe
durationandintensityofanticoagulanttherapyasper
recommendationsintheprevioussectiononDVTandPEin
children.

ChildrenWithVTEandStructurallyAbnormallyVenousSystems

ForchildrenwithfirstVTEsecondarytostructuralvenous
abnormalities,wesuggestanticoagulationasperother
spontaneousVTE(Recommendation2.22)andconsideration
ofsubsequentpercutaneousorsurgicalinterventions,
dependingonpatientfactorsandinstitutionalexperience.For
childrenwithrecurrentVTEsecondarytostructuralvenous
abnormalities,wesuggestindefiniteanticoagulationunless
successfulpercutaneousorsurgicalinterventionscanbe
performed(Grade2C).

ChildrenWithRightAtrialThrombosis
ForchildrenwithrightatrialthrombosisrelatedtoCVAD,we
suggestremovaloftheCVADwithorwithoutanticoagulation,
dependingontheindividualriskfactors,comparedwith
leavingtheCVADinsitu(Grade2C).Forchildrenwithlarge
(>2cm)mobilerightatrialthrombosis,wesuggest
anticoagulation,withappropriatelytimedCVADremoval,and
considerationofsurgicalinterventionorthrombolysisbasedon
individualizedriskbenefitassessmentcomparedwithno
anticoagulationtherapy(Grade2C).

ChildrenWithCVADs
ForCVADs,wesuggestflushingwithnormalsalineorheparin
orintermittentrecombinanturokinasetomaintainpatencyas
comparedwithnotherapy(Grade2C).ForblockedCVADs,we
suggesttPAorrecombinanturokinasetorestorepatency
(Grade2C).Ifafteratleast30minfollowinglocalthrombolytic
instillationCVADpatencyisnotrestored,wesuggestasecond
dosebeadministered.IftheCVADremainsblockedfollowing
twodosesoflocalthrombolyticagent,wesuggestradiologic
imagingtoruleoutaCVADrelatedthrombosis(Grade2C).

ChildrenWithCVADs
ForchildrenwithshortormediumtermCVADs,we
recommendagainsttheuseofroutinesystemic
thromboprophylaxis(Grade1B).

ChildrenUndergoingGlennProcedureorBilateralCavopulmonaryShunt

Forchildrenwhohavebilateralcavopulmonaryshunt,we
suggestpostoperativeUFH(Grade2C).

ChildrenUndergoingFontanSurgery
ForchildrenafterFontansurgery,werecommendaspirinor
therapeuticUFHfollowedbyVKAsovernotherapy(Grade
1C).

InsertionofEndovascularStentsinChildren

Forchildrenhavingendovascularstentsinserted,wesuggest
administrationofUFHperioperatively(Grade2C).

PediatricPatientsWithDilatedCardiomyopathy

Forpediatricpatientswithcardiomyopathy,wesuggestVKAs
nolaterthantheiractivationonacardiactransplantwaiting
list(Grade2C).
Valuesandpreferences:Parentswhoplaceahighvalueon
avoidingtheinconvenience,discomfort,andlimitationsof
anticoagulantmonitoringandalowervalueontheuncertain
reductioninthromboticcomplicationsareunlikelytochooseVKA
therapyfortheirchildrenwhoareeligiblefortransplant.

ChildrenWithPrimaryPulmonaryHypertension

Forchildrenwithprimarypulmonaryhypertension,wesuggest
startinganticoagulationwithVKAsatthesametimeasother
medicaltherapy(Grade2C).

ChildrenWithBiologicandMechanicalProstheticHeart
Valves

Forchildrenwithbiologicormechanicalprostheticheartvalves,
werecommendthatcliniciansfollowtherelevant
recommendationsfromtheadultpopulation.

ChildrenWithVentricularAssistDevices(VADs)

ForchildrenwithVADswesuggestadministrationofUFH
(Grade2C).WesuggeststartingUFHbetween8and48h
followingimplantation(Grade2C).Inaddition,wesuggest
antiplatelettherapy(eitheraspirinoraspirinand
dipyridamole)tocommencewithin72hofVADplacement
(Grade2C).ForchildrenwithVAD,onceclinicallystable,we
suggestswitchingfromUFHtoeitherLMWHorVKA(target
INR3.0range,2.53.5)untiltransplantedorweanedfromVAD
(Grade2C).

PrimaryProphylaxisforVenousAccessRelatedto
Hemodialysis
Forpatientsundergoinghemodialysisviaanarteriovenous
fistula,wesuggestroutineuseofVKAsorLMWHasfistula
thromboprophylaxisascomparedwithnotherapy(Grade2C).

PrimaryProphylaxisforVenousAccessRelatedto
Hemodialysis
ForpatientsundergoinghemodialysisviaCVAD,wesuggest
routineuseofVKAsorLMWHforthromboprophylaxisas
comparedwithnotherapy(Grade2C).

UseofUFHorLMWHinChildrenUndergoingHemodialysis

Forchildrenhavinghemodialysis,wesuggesttheuseofUFHor
LMWHduringhemodialysistomaintaincircuitpatency
independentoftypeofvascularaccess(Grade2C).

ChildrenWithKawasakiDisease
ForchildrenwithKawasakidisease,werecommendaspirinin
highdoses(80100mg/kgperdayduringtheacutephaseforup
to14days)asanantiinflammatoryagent,theninlowerdoses
(15mg/kgperdayfor6to8weeks)asanantiplateletagent
(Grade1B).ForchildrenwithKawasakidisease,we
recommendIVglobulin(2g/kg,singledose)within10days
oftheonsetofsymptoms(Grade1A).

ChildrenWithKawasakiDisease
Forchildrenwithmoderateorgiantcoronaryaneurysms
followingKawasakidisease,wesuggestthatwarfarinin
additiontolowdoseaspirinbegivenasprimary
thromboprophylaxis(Grade2C).

ChildrenWithKawasakiDisease
ForchildrenwithKawasakidiseasewhohavegiantaneurysms
andacutecoronaryarterythrombosis,wesuggestthrombolysis
oracutesurgicalintervention(Grade2C).

CSVTinChildren
ForchildrenwithCSVTwithoutsignificantintracranial
hemorrhage,werecommendanticoagulationinitiallywith
UFHorLMWHandsubsequentlywithLMWHorVKAfora
minimumof3monthsrelativetonoanticoagulation(Grade
1B).Inchildrenwhoafter3monthsoftherapystillexperience
occlusionofCSVTorongoingsymptoms,wesuggest
administrationofafurther3monthsofanticoagulation
(Grade2C).ForchildrenwithCSVTwithsignificant
hemorrhage,wesuggestinitialanticoagulationasforchildren
withouthemorrhageorradiologicmonitoringofthe
thrombosisat5to7daysandanticoagulationifthrombus
extensionisnotedatthattime(Grade2C).

CSVTinChildren
InchildrenwithCSVTandpotentiallyrecurrentriskfactors
(forexample,nephroticsyndrome,asparaginasetherapy),we
suggestprophylacticanticoagulationattimesofriskfactor
recurrence(Grade2C).Wesuggestthrombolysis,
thrombectomy,orsurgicaldecompressiononlyinchildrenwith
severeCSVTinwhomthereisnoimprovementwithinitial
UFHtherapy(Grade2C).

AISinChildren
ForchildrenwithacuteAIS,withorwithoutthrombophilia,we
recommendUFHorLMWHoraspirinasinitialtherapyuntil
dissectionandemboliccauseshavebeenexcluded(Grade1C).
ForchildrenwithacuteAIS,wesuggest,oncedissectionand
cardioemboliccausesareexcluded,dailyaspirinprophylaxis
foraminimumof2yearsascomparedwithnoantithrombotic
therapy(Grade2C).Forchildrenreceivingaspirinwhohave
recurrentAISortransientischemicattacks(TIAs),wesuggest
changingtoclopidogreloranticoagulanttherapywithLMWH
orVKA(Grade2C).ForchildrenwithAIS,werecommend
againsttheuseofthrombolysis(tPA)ormechanical
thrombectomyoutsideofspecificresearchprotocols(Grade1C).

EmbolicStrokeinChildren
ForAISsecondarytocardioemboliccauses,wesuggest
anticoagulanttherapywithLMWHorVKAsforatleast3
months(Grade2C).ForAISsecondarytocardioemboliccauses
inchildrenwithdemonstratedrighttoleftshunts(eg,PFO),we
suggestsurgicalclosureoftheshunt(Grade2C).

CerebralArterialDissectionUnderlyingAIS

ForAISsecondarytodissection,wesuggestanticoagulant
therapywithLMWHorVKAsforatleast6weeks(Grade2C).
Ongoingtreatmentwilldependonradiologicassessmentof
degreeandextentofstenosisandevidenceofrecurrent
ischemicevents.

ChildrenWithCerebralVasculopathies
ForchildrenwithacuteAISsecondarytononMoyamoya
vasculopathy,werecommendUFHorLMWHoraspirinfor3
monthsasinitialtherapycomparedwithnotreatment(Grade
1C).ForchildrenwithAISsecondarytononMoyamoya
vasculopathy,wesuggestongoingantithrombotictherapy
shouldbeguidedbyrepeatcerebrovascularimaging.

ChildrenWithMoyamoyaDisease

ForchildrenwithacuteAISsecondarytoMoyamoya,we
suggestaspirinovernotreatmentasinitialtherapy(Grade2C).

ChildrenWithMoyamoyaDisease
ForchildrenwithMoyamoyadisease,wesuggesttheybe
referredtoanappropriatecenterforconsiderationof
revascularization.

EndorsingOrganizations
Thisguidelinehasreceivedtheendorsementofthe
followingorganizations:
AmericanAssociationforClinicalChemistry
AmericanCollegeofClinicalPharmacy
AmericanSocietyofHealthSystemPharmacists
AmericanSocietyofHematology
InternationalSocietyofThrombosisandHemostasis

AcknowledgementofSupport
TheACCPappreciatesthesupportofthefollowingorganizations
forsomepartoftheguidelinedevelopmentprocess:
BayerScheringPharmaAG
NationalHeart,Lung,andBloodInstitute(GrantNo.R13HL104758)
Witheducationalgrantsfrom

BristolMyersSquibbandPfizer,Inc.
CanyonPharmaceuticals,and
sanofiaventisU.S.
Althoughtheseorganizationssupportedsomeportionofthedevelopment
oftheguidelines,theydidnotparticipateinanymannerwiththescope,
panelselection,evidencereview,development,manuscriptwriting,
recommendationdraftingorgrading,voting,orreview.Supportersdidnot
seetheguidelinesuntiltheywerepublished.