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Arends G, Perry E, Sherman A, Flint J. A Review of an Interfacility Transport Program Pediatric Stroke Clinical Practice Guideline. Pediatr Emerg Care 2024; 40:382-385. [PMID: 38194682 DOI: 10.1097/pec.0000000000003095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Pediatric acute ischemic stroke is a rare diagnosis that requires timely recognition and definitive management to prevent morbidity and mortality. Children often present to primary care offices, urgent care clinics, and adult emergency departments for evaluation of symptoms that may be signs and symptoms of stroke. Currently, there are no published prehospital or transport protocols specific to pediatric acute ischemic stroke. The Children's Mercy Hospital Critical Care Transport Team (CMCCT) created a pediatric-specific clinical practice guideline (CPG) for suspected acute ischemic stroke. METHODS This retrospective, descriptive study reports pediatric patients aged younger than 18 years who met criteria for the pediatric stroke CPG and required interfacility transport by CMCCT over a 4- year period. Large vessel occlusion (LVO) scores used in adults were calculated retrospectively. RESULTS Seventeen patients met inclusion criteria. Four (24%) of 17 had radiographic evidence of acute thrombus, 3 of whom received alteplase and/or endovascular clot retrieval. Median age of confirmed stroke was 83 months (interquartile range, 65-148) compared with 177 months for nonstroke (interquartile range, 169-191), P = 0.126. The most common presenting symptom was hemiplegia in the confirmed stroke group. The confirmed stroke group scored significantly lower on the Glasgow Coma Scale (median of 8 vs 15, P = 0.014), significantly higher on the Los Angeles Motor Scale LVO score (median 4 vs 0, P = 0.021), and significantly higher on the Rapid Arterial Occlusion Evaluation LVO (median 4 vs 0, P = 0.036). CONCLUSIONS To our knowledge, the CMCCT CPG is the first pediatric transport protocol aimed at recognition and management of pediatric stroke described in the literature. Retrospective calculation of LVO scores show that they may be helpful in application to pediatric patients.
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Affiliation(s)
- Grace Arends
- From the Children's Mercy Hospital, Kansas City, MO
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2
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Grubenhoff JA, Bakel LA, Dominguez F, Leonard J, Widmer K, Sanders JS, Spencer SP, Stein JM, Searns JB. Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections. Jt Comm J Qual Patient Saf 2023; 49:547-556. [PMID: 37495472 DOI: 10.1016/j.jcjq.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.
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3
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Phelps K, Silos C, De La Torre S, Moreno A, Lapus R, Sanghani N, Koenig M, Savitz S, Green C, Fraser S. Establishing a pediatric acute stroke protocol: experience of a new pediatric stroke program and predictors of acute stroke. Front Neurol 2023; 14:1194990. [PMID: 37273694 PMCID: PMC10232855 DOI: 10.3389/fneur.2023.1194990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Pediatric stroke is among the top 10 causes of death in pediatrics. Rapid recognition and treatment can improve outcomes in select patients, as evidenced by recent retrospective studies in pediatric thrombectomy. We established a collaborative protocol involving the vascular neurology and pediatric neurology division in our institution to rapidly diagnose and treat pediatric suspected stroke. We also prospectively collected data to attempt to identify predictors of acute stroke in pediatric patients. Methods IRB approval was obtained to prospectively collect clinical data on pediatric code stroke activations based on timing metrics in resident-physician note templates. The protocol emphasized magnetic resonance imaging over computed tomography imaging when possible. We analyzed performance of the system with descriptive statistics. We then performed a Bayesian statistical analysis to search for predictors of pediatric stroke. Results There were 40 pediatric code strokes over the 2.5-year study period with a median age of 10.8 years old. 12 (30%) of patients had stroke, and 28 (70%) of code stroke patients were diagnosed with a stroke mimic. Median time from code stroke activation to completion of imaging confirming or ruling out stroke was 1 h. In the Bayesian analysis, altered mental status, hemiparesis, and vasculopathy history were associated with increased odds of stroke, though credible intervals were wide due to the small sample size. Conclusion A trainee developed and initiated pediatric acute stroke protocol quickly implemented a hospital wide change in management that led to rapid diagnosis and triage of pediatric stroke and suspected stroke. No additional personnel or resources were needed for this change, and we encourage other hospitals and emergency departments to implement similar systems. Additionally, hemiparesis and altered mental status were predictors of stroke for pediatric acute stroke activation in our Bayesian statistical analysis. However credible intervals were wide due to the small sample size. Further multicenter data collection could more definitively analyze predictors of stroke, as well as the help in the creation of diagnostic tools for clinicians in the emergency setting.
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Affiliation(s)
- Kamal Phelps
- University of Texas McGovern Medical School, Houston, TX, United States
| | - Christin Silos
- School of Biomedical Informatics, The University of Texas Health Science Center Houston, Houston, TX, United States
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Susan De La Torre
- Department of Internal Medicine, University of Illinois College of Medicine, Chicago, IL, United States
| | - Amee Moreno
- Baylor University Louise Herrington School of Nursing, Dallas, TX, United States
| | - Robert Lapus
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Nipa Sanghani
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Mary Koenig
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Sean Savitz
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Charles Green
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
| | - Stuart Fraser
- The UTHealth Institute for Stroke and Cerebrovascular Disease, The University of Texas Health Science Center, Houston, TX, United States
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School, Houston, TX, United States
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Mills MG, Reichhold A, Maciorowski K, Joong A, Kurz J, Pardo AC. Stroke Diagnosis Protocol for Children With Ventricular Assist Devices. ASAIO J 2023; 69:e199-e204. [PMID: 36696479 DOI: 10.1097/mat.0000000000001858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Ventricular assist devices (VADs) are increasingly used for end-stage heart failure in children. VAD-associated neurologic dysfunction, including stroke and intracranial hemorrhage, occurs in more than 20% of patients. Starting in 2019, we implemented a protocol to diagnose stroke in relation to VAD to facilitate treatment. A multidisciplinary approach was implemented including targeted education for providers. VAD goals, structured neurologic exam, and frequency of neuromonitoring were incorporated into daily rounds, tailored to patient's phase of recovery. A protocolized neurocritical team assessment was implemented. A VAD-specific stroke algorithm and order set were implemented to facilitate rapid neuroimaging. We performed a pre- and postimplementation analysis from 2015 to 2020. Forty-six patients had VADs placed, 25 preintervention, and 21 postintervention. We compared the number of patients evaluated for stroke, time to imaging, and documentation of last known normal exam. Preintervention, time to imaging was 7 hours, and documentation was inconsistent. Postintervention, time to imaging decreased to 2.8 hours ( p = 0.038) with universal documentation of last known normal ( p = 0.009). The use of head computerized tomographies decreased from 11 preintervention to three postintervention. Development of a VAD protocol decreased time to imaging for suspected stroke and reduced unnecessary imaging. Further studies are required to validate these data.
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Affiliation(s)
- Michele G Mills
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Allison Reichhold
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Heart Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Kim Maciorowski
- Center for Quality and Safety, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anna Joong
- Division of Pediatric Cardiology, Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan Kurz
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Merck & Co., Kenilworth, New Jersey
| | - Andrea C Pardo
- From the Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bindslev JB, Hansen K, Laugesen NG, Benndorf G, Hoei-Hansen CE, Truelsen T. Acute triage of childhood stroke in Denmark. Eur Stroke J 2023; 8:483-491. [DOI: 10.1177/23969873231161381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Objective: This 2-year observational study aimed to test the feasibility of implementing a pediatric stroke triage-setup that connected frontline providers with vascular neurologists and to examine final diagnoses in children triaged for suspected stroke. Methods: Prospective, consecutive registration of children with suspected stroke triaged by a team of vascular neurologists from Jan 1st, 2020 and through Dec 2021, Eastern Denmark (census 530,000 children). Based on the provided clinical information, the children were triaged to either assessment at the Comprehensive Stroke Center (CSC) in Copenhagen or to a pediatric department. All included children were retrospectively followed-up for clinical presentations and final diagnosis. Results: A total of 163 children with 166 suspected stroke events were triaged by the vascular neurologists. Cerebrovascular disease was present in 15 (9.0%) suspected stroke events; one child had intracerebral hemorrhage, one had subarachnoid hemorrhage, two children presented with three TIA events and nine children presented with 10 ischemic stroke events. Two children with ischemic stroke were eligible for acute revascularization treatment of which both were triaged to the CSC. The sensitivity of the triage by acute revascularization indication was 1.00 (95% confidence interval (95% CI): 0.15–1.00) and specificity 0.65 (95% CI: 0.57–0.73). Non-stroke neurological emergencies were present in 34 (20.5%) children, including seizures in 18 (10.8%) and acute demyelinating disorders in 7 (4.2%). Conclusion: Implementing regional triage-setup that connected frontline providers to vascular neurologists was feasible; this system was activated for the majority of children with ischemic stroke according to an expected incidence and led to identification of children eligible for revascularization treatments.
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Affiliation(s)
- Julie Brix Bindslev
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Goetz Benndorf
- Department of Radiology, University Hospital of Copenhagen, Rigshopitalet, Copenhagen, Denmark
- Baylor College of Medicine, Houston, TX, USA
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Pangprasertkul S, Borisoot W, Buawangpong N, Sirikul W, Wiwattanadittakul N, Katanyuwong K, Sanguansermsri C. Comparison of Arterial Ischemic and Hemorrhagic Pediatric Stroke in Etiology, Risk Factors, Clinical Manifestations, and Prognosis. Pediatr Emerg Care 2022; 38:e1569-e1573. [PMID: 35113509 DOI: 10.1097/pec.0000000000002614] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke is relatively rare in children but has a significant impact on long-term morbidity and mortality. There are limited data regarding the etiology, clinical manifestation, and prognosis of arterial ischemic stroke (AIS) and hemorrhagic stroke (HS) in children. OBJECTIVE The aim of this study is to identify and compare etiology, risk factors, clinical manifestations, and prognostic outcomes between arterial ischemic and hemorrhagic pediatric stroke. METHODS We retrospectively reviewed all hospital medical records and pediatric neurology database of 83 children who were first diagnosed with AIS and HS at the Pediatric Department, Chiang Mai University Hospital, Chiang Mai, Thailand between January 1, 2009, and December 31, 2018. All children were from 1 month to 18 years old. RESULTS Fifty-one AIS (56%) and 32 (35.2%) HS were identified. The median age of onset was 6.9 years for AIS and 5.3 years for HS. Moyamoya disease/syndrome was the most common cause in AIS (21.6%). Rupture of cerebral arteriovenous malformation was the most common cause in HS (21.9%). More than one-third (39%) of children had multiple risk factors associated with stroke. Iron deficiency anemia was commonly found in children with AIS (39.2%). The majority of clinical presentations were hemiparesis (80.4%) for AIS and alteration of consciousness (68.8%) for HS. The median time to diagnosis exceeded 6 hours in both AIS and HS. The overall mortality rate of acute stroke was 5.1 per 100 person-years (95% confidence interval [CI], 2.9-9). The mortality rate was higher in HS compared with that in AIS with statistical significance (16.6; 95% CI, 8.9-30.8 vs 1.1%; 95% CI, 0.3-4.6 per 100 person-years). Thirty children (36.1%) developed epilepsy during the follow-up (median duration, 26 months). Recurrent stroke occurred in 1 child with AIS and 1 child with HS. CONCLUSIONS Moyamoya disease/syndrome and arteriovenous malformation rapture are the most common cause of AIS and HS, respectively. Iron deficiency anemia was commonly found in childhood AIS. The time to diagnosis in both AIS and HS was delayed. The mortality rate in HS was higher than in AIS. Neurological deficits are seen in 70% of childhood AIS during the follow-up. One-third of the children in our study developed epilepsy, which generally responds to a single antiseizure medication. The recurrence rate of childhood stroke was low compared with adult stroke.
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Affiliation(s)
| | | | | | | | - Natrujee Wiwattanadittakul
- Neurology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Kamornwan Katanyuwong
- Neurology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
| | - Chinnuwat Sanguansermsri
- Neurology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
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8
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Successful Outcome in an Adolescent with Artery of Percheron Occlusion who was Treated with Tissue Plasminogen Activator. J Emerg Med 2022; 63:300-303. [PMID: 35840436 DOI: 10.1016/j.jemermed.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ischemic stroke is relatively rare in children, leading to a low level of suspicion and delayed diagnosis, particularly in cases of posterior circulation occlusion when symptoms are less indicative. Occlusion of the artery of Percheron (AOP) results in nonspecific neurologic symptoms, including drowsiness, aphasia or dysarthria, ophthalmoplegia, ataxia, and dysmetria. Previous reports, mainly in adults, described late diagnosis and severe residual disability. CASE REPORT We report a case of a 16-year-old male who presented to the pediatric emergency department with altered mental status. There was no history of trauma or intoxication. The main symptoms included confusion, slurred speech, and multiple falls starting 1 h before arrival to the emergency department. No motor deficits or other focal signs were noticed. The patient's consciousness gradually decreased followed by apneic events. Routine laboratory tests, urinary toxic screen, and a computed tomography scan of the head were normal. A magnetic resonance imaging scan of the brain revealed bilateral restrictive changes in the thalamus. A diagnosis of AOP occlusion was made, and the patient was treated with tissue plasminogen activator (6 h after symptom onset). He was extubated on day 4 and discharged on the day 10 of admission without any neuropsychological deficit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Posterior circulation stroke in the pediatric population is a diagnostic challenge that often results in suboptimal treatment and unfavorable outcomes. Prompt imaging studies in children with nonspecific altered mental status enable timely diagnosis and thrombolytic treatment that may substantially improve the outcome.
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Bhatia KD, Briest R, Goetti R, Webster R, Troedson C, Dale RC, Muthusami P, Miteff C, Miteff F, Worthington J, Tastula K, Ang T, Andrews I. Incidence and Natural History of Pediatric Large Vessel Occlusion Stroke: A Population Study. JAMA Neurol 2022; 79:488-497. [PMID: 35344005 PMCID: PMC8961400 DOI: 10.1001/jamaneurol.2022.0323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The incidence and natural history of large vessel occlusion (LVO) stroke in children is largely unknown. These knowledge gaps limit the uptake of reperfusion therapies and reduce the efficiency of pediatric acute stroke pathways. Objective To determine the incidence and natural history of pediatric LVO stroke. Design, Setting, and Participants This retrospective population-based cohort study was conducted between January 2010 and December 2019, with a mean (SD) follow-up of 37.0 (28.8) months. Admissions from all pediatric hospitals in the state of New South Wales, Australia, with a final diagnosis of arterial ischemic stroke (AIS) in patients 1 month to younger than 17 years were included. A total of 85 of 251 identified cases were excluded based on selection criteria. Data were analyzed from July 2020 to June 2021. Exposures One-third of patients with LVO received mechanical thrombectomy with or without intravenous thrombolysis while the remainder were treated conservatively. Main Outcomes and Measures The primary outcome was the pediatric modified Rankin Scale (ped-mRS) score 3 months after stroke. Ordinal logistic regression was used to compare non-LVO, LVO without thrombectomy, and LVO with thrombectomy groups. Results Of 161 included patients, 56 (34.8%) were female, and the mean (SD) age was 6.1 (5.4) years. A total of 166 AIS admissions were studied, and clinical follow-up was available for 164 of 166 admissions. LVO was present in 39 admissions (23.5%). The incidence of LVO stroke was 0.24 per 100 000 patients per year (95% CI, 0.13-0.35). Patients with LVO who did not receive thrombectomy (n = 26) had poor neurological outcomes, with 19 (73.1%) experiencing moderate to severe disability or death (ped-mRS score of 3 to 6) at 3 months (6 of 12 patients receiving thrombectomy [50.0%]; 25 of 38 patients with LVO [65.8%]). Patients with LVO without thrombectomy had significantly worse clinical outcomes than patients with non-LVO at 3 months (odds ratio, 3.64; 95% CI, 1.68-7.87; P = .001). Most patients with LVO presented within time windows suitable for thrombectomy (27 of 39 [69.2%] within 6 hours; 35 of 39 [89.7%] within 24 hours). Conclusions and Relevance In this population-based cohort study, the natural history of pediatric patients with LVO stroke treated conservatively was poor, with most experiencing lifelong disability or death. Nearly 90% of pediatric patients with LVO presented within time windows suitable for thrombectomy.
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Affiliation(s)
- Kartik D Bhatia
- Department of Medical Imaging, Children's Hospital at Westmead, Westmead, Australia.,Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia.,Faculty of Medicine, Macquarie University, Sydney, Australia
| | - Romain Briest
- Department of Neurology, Sydney Children's Hospital, Randwick, Sydney, Australia
| | - Robert Goetti
- Department of Medical Imaging, Children's Hospital at Westmead, Westmead, Australia
| | - Richard Webster
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia.,T.Y. Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Westmead, Australia
| | - Christopher Troedson
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia.,T.Y. Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Westmead, Australia
| | - Russell C Dale
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia.,T.Y. Nelson Department of Neurology and Neurosurgery, Children's Hospital at Westmead, Westmead, Australia
| | - Prakash Muthusami
- Division of Image-Guided Therapy, Department of Radiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Miteff
- Department of Neurology, John Hunter Children's Hospital, New Lambton Heights, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, New Lambton Heights, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Kylie Tastula
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Timothy Ang
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Ian Andrews
- Department of Neurology, Sydney Children's Hospital, Randwick, Sydney, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, Australia
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10
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Harrar DB, Benedetti GM, Jayakar A, Carpenter JL, Mangum TK, Chung M, Appavu B. Pediatric Acute Stroke Protocols in the United States and Canada. J Pediatr 2022; 242:220-227.e7. [PMID: 34774972 DOI: 10.1016/j.jpeds.2021.10.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures. STUDY DESIGN We administered an Internet-based survey of pediatric stroke specialists. The survey included questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke response, imaging, and hyperacute treatment. RESULTS Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke. Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing, the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page. Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbreviated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator (IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey. CONCLUSIONS An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.
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Affiliation(s)
- Dana B Harrar
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Giulia M Benedetti
- Department of Neurology, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Tara K Mangum
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
| | - Melissa Chung
- Divisions of Critical Care Medicine and Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Brian Appavu
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
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11
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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12
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Acute ischemic stroke in childhood: a comprehensive review. Eur J Pediatr 2022; 181:45-58. [PMID: 34327611 PMCID: PMC8760225 DOI: 10.1007/s00431-021-04212-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/10/2021] [Accepted: 07/15/2021] [Indexed: 12/27/2022]
Abstract
This review provides an updated analysis of the main aspects involving the diagnosis and the management of children with acute ischemic stroke. Acute ischemic stroke is an emergency of rare occurrence in children (rate of incidence of 1/3500 live birth in newborns and 1-2/100,000 per year during childhood with peaks of incidence during the perinatal period, under the age of 5 and in adolescence). The management of ischemic stroke in the paediatric age is often challenging because of pleomorphic age-dependent risk factors and aetiologies, high frequency of subtle or atypical clinical presentation, and lacking evidence-based data about acute recanalization therapies. Each pediatric tertiary centre should activate adequate institutional protocols for the optimization of diagnostic work-up and treatments.Conclusion: The implementation of institutional standard operating procedures, summarizing the steps for the selection of candidate for neuroimaging among the ones presenting with acute neurological symptoms, may contribute to shorten the times for thrombolysis and/or endovascular treatments and to improve the long-term outcome. What is Known: •Acute ischemic stroke has a higher incidence in newborns than in older children (1/3500 live birth versus 1-2/100,000 per year). •Randomized clinical trial assessing safety and efficacy of thrombolysis and/or endovascular treatment were never performed in children What is New: •Recent studies evidenced a low risk (2.1% of the cases) of intracranial haemorrhages in children treated with thrombolysis. •A faster access to neuroimaging and hyper-acute therapies was associated with the implementation of institutional protocols for the emergency management of pediatric stroke.
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13
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Appavu B, Deng D, Dowling MM, Garg S, Mangum T, Boerwinkle V, Abruzzo T. Arteritis and Large Vessel Occlusive Strokes in Children After COVID-19 Infection. Pediatrics 2021; 147:peds.2020-023440. [PMID: 33277353 DOI: 10.1542/peds.2020-023440] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 11/24/2022] Open
Abstract
We describe 2 previously healthy children who suffered disabling arterial ischemic strokes because of acute intracranial large vessel occlusion within 3 to 4 weeks of coronavirus disease 2019 (COVID-19) infection. Both children presented from communities with high COVID-19 case rates in the Southwest United States. An 8-year-old American Indian girl experienced severe iron deficiency anemia requiring blood transfusion and presented with bilateral middle cerebral artery (MCA) distribution strokes 3 weeks later. She underwent emergent mechanical thrombectomy of the left MCA with successful clot retrieval but experienced reocclusion of that artery 5 hours after intervention. She also had evidence of cerebral arteritis on catheter angiography and vessel wall imaging, and clot pathology revealed recently formed, unorganized platelet- and fibrin-rich thrombus with sparse clusters of erythrocytes, degenerated histiocytes, few eosinophils, and rare neutrophils. A 16-year old African American boy demonstrated evidence of arteritis on brain magnetic resonance angiography and serological markers of cardiac and renal injury accompanied by positive lupus anticoagulant antibodies. The children described in this report express clinical features inconsistent with focal cerebral arteriopathy, including elevated markers of systemic inflammation in both bilateral MCA strokes in one case and multiple organ system dysfunction in the other case. Neither patient fulfilled criteria for multisystem inflammatory syndrome in children, given absence of fever. These cases illustrate that systemic postinfectious arteritis with cerebrovascular involvement may complicate COVID-19 infection in previously healthy school-aged children, and their presentations may overlap but not fulfill criteria for multisystem inflammatory syndrome in children or focal cerebral arteriopathy.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute and .,Contributed equally as co-first authors
| | - Doris Deng
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas; and.,Contributed equally as co-first authors
| | - Michael Morgan Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | | | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute and
| | | | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute and.,Radiology, Phoenix Children's Hospital and College of Medicine - Phoenix, The University of Arizona, Phoenix, Arizona
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14
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Chabrier S, Ozanne A, Naggara O, Boulouis G, Husson B, Kossorotoff M. Hyperacute Recanalization Strategies and Childhood Stroke in the Evidence Age. Stroke 2020; 52:381-384. [PMID: 33349018 DOI: 10.1161/strokeaha.120.031133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
No controlled pharmacological studies are available in the field of pediatric stroke, except for sickle cell disease. Therefore, while pharmacological and mechanical recanalization treatments have repeatedly shown clinical benefit in adults with arterial ischemic stroke, pediatric strokologists still cannot base their therapeutic management (including hyperacute strategies) on high-level evidence. Once again, pediatricians face the same dichotomic choice: adapting adult procedures now versus waiting-for a long time-for the corresponding pediatric trials. One way out is building a compromise based on observational studies with large, longitudinal, comprehensive, real-life, and multisource dataset. Two recent high-quality observational studies have delivered promising conclusions on recanalization treatments in pediatric arterial ischemic stroke. TIPSTER (Thrombolysis in Pediatric Stroke Extended Results) showed that the risk of severe intracranial hemorrhage after intravenous thrombolysis is low; the Save Childs Study reported encouraging data about pediatric thrombectomy. Beyond the conclusion of a satisfactory global safety profile, a thorough analysis of the methods, populations, results, and therapeutic complications of these studies helps us to refine indications/contraindications and highlights the safeguards we need to rely on when discussing thrombolysis and thrombectomy in children. In conclusion, pediatric strokologists should not refrain from using clot lysis/retrieval tools in selected children with arterial ischemic stroke. But the implementation of hyperacute care is only feasible if the right candidate is identified through the sharing of common adult/pediatric protocols and ward collaboration, formalized well before the child's arrival. These anticipated protocols should never undervalue contraindications from adult guidelines and must involve the necessary pediatric expertise when facing specific causes of stroke, such as focal cerebral arteriopathy of childhood.
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Affiliation(s)
- Stéphane Chabrier
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Inserm, Université Saint-Étienne, UMR1059, Saint-Étienne, France (S.C.)
| | - Augustin Ozanne
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Department of Interventional Neuroradiology Neuro Brain Vascular Center, Assistance publique-Hôpitaux de Paris, Paris-Saclay University, Hôpital Bicêtre, le Kremlin-Bicêtre, France (A.O.)
| | - Olivier Naggara
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France (O.N., G.B.).,GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France (O.N., G.B.)
| | - Grégoire Boulouis
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Hôpital Necker-Enfants malades, Paris, France (O.N., G.B.).,GHU Paris Psychiatrie et Neurosciences, CH Sainte-Anne, Inserm, Université de Paris, Institut de psychiatrie et neurosciences de Paris, Service d'imagerie morphologique et fonctionnelle, UMRS1266, Paris, France (O.N., G.B.)
| | - Béatrice Husson
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Radiology Department, Assistance publique-Hôpitaux de Paris, Université de Paris-Saclay, Hôpital Bicêtre, le Kremlin-Bicêtre, France (B.H.)
| | - Manoëlle Kossorotoff
- Assistance publique-Hôpitaux de Paris, CHU Saint-Étienne, CH Sainte-Anne, French Center for Pediatric Stroke, France (S.C., A.O., O.N., G.B., B.H., M.K.).,Pediatric Neurology Department, Assistance publique-Hôpitaux de Paris, Inserm, Hôpital Necker-Enfants malades, Paris, France (M.K.)
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15
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Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1578-1586. [PMID: 33392566 PMCID: PMC7771757 DOI: 10.1002/emp2.12275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023] Open
Abstract
Strokes are more commonly seen in adults but also occur in the pediatric population. Similar to adult strokes, pediatric strokes are considered medical emergencies and require prompt diagnosis and treatment to maximize favorable outcomes. Unfortunately, the diagnosis of stroke in children is often delayed, commonly because of parental delay or failure to consider stroke in the differential diagnosis. Children, especially young children, often present differently than adults. Much of the treatment for pediatric strokes has been adapted from adult guidelines but the optimal treatment has not been clearly defined. In this article, we review pediatric strokes and the most recent recommendations for treatment.
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Affiliation(s)
- Michael D. Baldovsky
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Pamela J. Okada
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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16
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Wharton JD, Barry MM, Lee CA, Massey K, Ladner TR, Jordan LC. Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years. J Pediatr 2020; 220:214-220.e1. [PMID: 32147216 DOI: 10.1016/j.jpeds.2020.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the implementation and utilization of a pediatric acute stroke protocol over a 7-year period, hypothesizing improvements in protocol implementation and increased protocol use over time. STUDY DESIGN Clinical and demographic data for this retrospective observational study from 2011 through 2018 were obtained from a quality improvement database and medical records of children for whom the acute stroke protocol was activated. The initial 43 months of the protocol (period 1) were compared with the subsequent 43 months (period 2). RESULTS Over the 7-year period, a total of 385 stroke alerts were activated, in 150 children (39%) in period 1 and 235 (61%) in period 2, representing a 56% increase in protocol activation. Stroke was the final diagnosis in 80 children overall (21%), including 38 (25%) in period 1 and 42 (19%) in period 2 (P = .078). The combined frequency of diagnosed stroke, transient ischemic attack (TIA), and other neurologic emergencies remained stable across the 2 time periods at 39% and 37%, respectively (P = .745). Pediatric National Institutes of Health Stroke Scale (PedNIHSS) documentation increased from 42% in period 1 to 82% in period 2 (P < .001). Magnetic resonance imaging (MRI) was the first neuroimaging study for 68% of the children in period 1 vs 78% in period 2 (P = .038). All children with acute stroke received immediate supportive care. CONCLUSIONS Pediatric stroke protocol implementation improved over time with increased use of the PedNIHSS and use of MRI as the first imaging study. However, with increased utilization, the frequency of confirmed strokes and other neurologic emergencies remained stable. The frequency of stroke and other neurologic emergencies in these children affirms the importance of implementing and maintaining a pediatric acute stroke protocol.
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Affiliation(s)
- Jessica D Wharton
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Megan M Barry
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Neurology, University of Colorado, Aurora, CO
| | - Chelsea A Lee
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Travis R Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN.
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17
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Katsanos AH. Save ChildS With Large Vessel Occlusion Using Commonly Available Endovascular Devices? Stroke 2020; 51:1049-1050. [PMID: 32114930 DOI: 10.1161/strokeaha.120.029166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aristeidis H Katsanos
- From the Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
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