Pediatric Acute Stroke Protocol Activation in a Children’s Hospital Emergency Department

Abstract

Background and Purpose-Pediatric acute stroke teams are a new phenomenon. We sought to characterize the final diagnoses of children with brain attacks in the emergency department where the pediatric acute stroke protocol was activated and to describe the time to neurological evaluation and neuroimaging. Methods-Clinical and demographic information was obtained from a quality improvement database and medical records for consecutive patients (age, ≤20 years) presenting to a single institution's pediatric emergency department where the acute stroke protocol was activated between April 2011 and October 2014. Stroke protocol activation means that a neurology resident evaluates the child within 15 minutes, and urgent magnetic resonance imaging is available. Results-There were 124 stroke alerts (age, 11.2±5.2 years; 63 boys/61 girls); 30 were confirmed strokes and 2 children had a transient ischemic attack. Forty-six of 124 (37%) cases were healthy children without any significant medical history. Nonstroke neurological emergencies were found in 17 children (14%); the majority were meningitis/encephalitis (n=5) or intracranial neoplasm (n=4). Other common final diagnoses were complex migraine (17%) and seizure (15%). All children except 1 had urgent neuroimaging. Magnetic resonance imaging was the first study in 76%. The median time from emergency department arrival to magnetic resonance imaging was 94 minutes (interquartile range, 49-151 minutes); the median time to computed tomography was 59 minutes (interquartile range, 40-112 minutes). Conclusions-Of pediatric brain attacks, 24% were stroke, 2% were transient ischemic attack, and 14% were other neurological emergencies. Together, 40% had a stroke or other neurological emergency, underscoring the need for prompt evaluation and management of children with brain attacks.

A pediatric institutional acute stroke protocol improves timely access to stroke treatment

“…The study, conducted from 2011 to 2014 reported 124 stroke alerts in a pediatric emergency room, including 30 children with stroke. 7 MRI, the initial imaging study in 76%, was completed at median 94 minutes from hospital arrival compared to 59 minutes for CT. These data prove the feasibility of rapid MRI as a first imaging test and provide a criterion standard to which all specialized pediatric stroke centers can aspire.…”

“…Children present age-related challenges to timely diagnosis, including stroke mimics in 30% to 75% and subtle clinical presentations, which necessitates neuroimaging confirmation of stroke before administering treatment. [5][6][7] Seizures in 22% to 25% at pediatric stroke onset (10-fold increase over adults) confound stroke diagnosis, accelerate ischemic injury, and entail urgent consideration of anticonvulsants for neuroprotection. 8,9 Studies to date, however, report intervals of 16 to 25 hours from symptom onset to stroke diagnosis 1,8,[10][11][12][13][14] far beyond 4.5 to 6 hours, the time window recommended for thrombolysis or embolectomy in adults.…”

Stroke Diagnosis in the Pediatric Emergency Department

“…11 Neuroimaging was required to differentiate strokes from mimics. 10,11 The present study underscores the high frequency of stroke mimics in children, which makes the job of emergency physician evaluators even more difficult. Although the overall specificity of ED physician suspicion of stroke was high, the sensitivity was only moderate to good.…”

“…In another study of final diagnoses among 124 stroke alerts in a pediatric ED, 76% had stroke mimics. 10 However, in a different tertiary care hospital cohort, only 21% of children evaluated by the stroke team for acute presentations concerning for stroke had mimics. 11 Neuroimaging was required to differentiate strokes from mimics.…”

“…Furthermore, MRI was the first study in over 75% of children. 10 At a non-TIPS center, after implementation of a pediatric stroke clinical pathway, the median time from ED arrival to MRI decreased from 17 hours to 4 hours. 3 The triggers for this pediatric stroke clinical pathway were detailed and included presenting neurological symptoms and pertinent medical history, such as congenital heart disease or sickle cell disease.…”