Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway

Design and Interrater Reliability of the Pediatric Version of the Race Scale: PedRACE

BACKGROUND

Acute ischemic stroke is a leading cause of pediatric death and disability. A clinical scale adapted for children can ensure early detection of candidates for urgent acute ischemic stroke treatment. The Rapid Arterial Occlusion Evaluation (RACE) scale for adults, which scores 5 items (facial palsy 0-2; arm motor function 0-2; leg motor function 0-2; head/gaze deviation 0-1; and aphasia or agnosia 0-2), has good sensitivity and specificity in detecting large vessel occlusion.

METHODS

We adapted the previously validated RACE scale for use in children as the Pediatric RACE scale. This adapted scale was tested by prehospital/emergency room staff attending to patients covered by the Catalan Pediatric Stroke Code and child neurologists for its correlation with the Pediatric National Institutes of Health Stroke Scale and for interrater reliability.

RESULTS

The study included 50 children, 18 with confirmed strokes (7 acute ischemic strokes and 11 hemorrhagic strokes). Prehospital/emergency staff and child neurologists agreed fully regarding 82% of patients and 100% regarding head/gaze deviation and agnosia. The Pediatric RACE scale correlated strongly with the Pediatric National Institutes of Health Stroke Scale in evaluations by child neurologists (Spearman ρ, 0.852; P<0.001) and prehospital/emergency staff (Spearman ρ, 0.781; P<0.001). The median Pediatric RACE score was significantly higher in patients with large vessel occlusion (6.5; interquartile range, 6-7) than with other etiologies.

CONCLUSIONS

Pediatric RACE, showing good interrater reliability and correlation with the Pediatric National Institutes of Health Stroke Scale, is a simple scale to detect candidates for pediatric acute stroke treatment, designed for both prehospital and in-hospital use by non-neurologist medical staff.

This infant is having a stroke: an illustrative case report

BACKGROUND

Paediatric stroke is a rare event, and timely intervention is required to minimise long-term disability, reduced quality of life and financial implications. Although reperfusion strategies such as thrombolysis and thrombectomy are now well established in the adult population, and paediatric consensus guidelines allow for reperfusion therapies in children, access is currently limited due to diagnostic delays. This challenge is partly due to the rarity of presentation, infrastructure and public awareness to support early diagnosis as exists in the adult setting. We use an illustrative case and literature to describe an achieved case of paediatric stroke within an Irish setting.

METHODS

We use the case of an 8-month-old male infant presenting with acute-onset left-sided hemiplegia to illustrate what can be achieved in an Irish setting.

RESULTS

Stroke was identified quickly following presentation, timely neuroimaging and multidisciplinary involvement with disposition to paediatric intensive care unit where thrombolysis was administered. Although the patient has some speech delay, he is recovering well with normal gross motor function.

CONCLUSIONS

Paediatric stroke care should be available to all children presenting with acute stroke symptoms; however, the rarity of the diagnosis would suggest a national strategy will be required to provide equitable care at a national level.

Acute triage of childhood stroke in Denmark

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.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.

Robotic-Assisted Hand Therapy with Gloreha Sinfonia for the Improvement of Hand Function after Pediatric Stroke: A Case Report

Background: Stroke in childhood presents a serious rehabilitation challenge since it leads to physical, cognitive and psychosocial disability. The objective of our study was to describe the effectiveness of robot-mediated therapy (RMT) with Gloreha Sinfonia in addition to a conventional treatment in the recovery of the sensory-motor capabilities of the paretic hand and the quality of life in a ten-year-old child after a stroke. Methods: The girl was enrolled to undergo 10 sessions of RMT with Gloreha Sinfonia. She was evaluated with functional scales and with upper limb kinematic analysis at pre-treatment (T0) and at the end of treatment (T1). Outcome measures were Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Visual Analogic Scale (VAS) and Activities and Participation of Daily Life (ADL). In addition, a Force Assessment System based on Virtual Reality games was used to assess the force control and modulation capability at T0 and T1. Results: At the end of treatment, the patient improved in functional scales and in quality of life for greater involvement in some activity of daily living. Force control and modulation capability significantly increased after the treatment. Conclusions: This clinical case highlights possible positive effects of a combined (conventional plus robotic) rehabilitation treatment for the upper limb in pediatric stroke outcomes from both a sensorimotor and functional point of view, also improving the motivational and affective aspects of the patient and of family members. Further studies are needed to validate these results and to identify the most appropriate modalities and doses.

Ischemic stroke mimics: A comprehensive review

BACKGROUND

Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

METHODS

The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

RESULTS

Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

CONCLUSION

Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

Initial Diagnostic Evaluation of the Child With Suspected Arterial Ischemic Stroke

ABSTRACT

Numerous factors make the initial diagnostic evaluation of children with suspected arterial ischemic stroke (AIS) a relatively unsettling challenge, even for the experienced stroke specialist. The low frequency of pediatric AIS, diversity of unique age-oriented stroke phenotypes, and unconventional approaches required for diagnosis and treatment all contribute difficulty to the process. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with diagnostic decision making in the initial phase of care.

Performance of a Pediatric Stroke Alert Team Within a Comprehensive Stroke Center

BACKGROUND

Childhood stroke is rare, and diagnosis is frequently delayed. The use of pediatric stroke teams has the potential to decrease time to neurology evaluation and imaging, hastening appropriate diagnosis and treatment for acute neurologic presentations in children.

METHODS

We performed a retrospective analysis of our institutional pediatric stroke or "brain attack" team (pedsBAT) activations from October 2014 to July 2017. Clinical characteristics and timing parameters were compared between pedsBAT activations in the inpatient vs emergency department (ED) / outpatient settings as well as between pediatric and adult BAT activations in the same time period.

RESULTS

We identified 120 pedsBAT activations (75% in the ED/outpatient setting) during the study time period. Inpatient pedsBAT activations were more likely than outpatient activations to have heart disease as a risk factor for ischemic stroke and presented more frequently with altered mental status, but there were no differences in the proportion of cerebrovascular diagnoses or timing parameters between the 2 groups. When compared with adult BAT activations, outpatient pedsBAT activations had a longer time from symptom discovery to arrival at the ED, and inpatient pedsBAT activations had longer time from symptom discovery to BAT activation.

CONCLUSIONS

Compared with adults, the interval leading up to stroke team activation was longer in children, suggesting delays in symptom recognition. Future interventions should be aimed at reducing these delays in presentation to care and stroke alert activation in pediatric patients.

Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years

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.