The Way Forward: Challenges and Opportunities in Pediatric Stroke

Roadmap for the Assessment and Management of Outcomes in Pediatric Stroke

Neurological morbidity is common after pediatric stroke, with moderate to severe deficits that can significantly impact education and social function. Care and recovery occur in phases distinguished by the time interval after stroke onset. These phases include the hyperacute and acute periods in which the focus is on cerebral reperfusion and prevention of neurological deterioration, followed by the subacute and chronic phases in which the focus is on secondary stroke prevention and mitigation of disability through rehabilitation, adaptation, and reintegration into the community. In this article, a multidisciplinary group of pediatric stroke experts review the stages of recovery after pediatric stroke with an emphasis on critical assessment time points. Our goal is to encourage increased standardization of outcome assessment to facilitate future clinical trials comparing various treatment and intervention options and advance optimized care for children with stroke.

ACR Appropriateness Criteria® Cerebrovascular Disease-Child

Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Primary Intraventricular Hemorrhage in Pediatric Patients: Causes, Characteristics, and Outcomes

BACKGROUND

Primary intraventricular hemorrhage (PIVH) is rare, and causes, characteristics, and outcomes remain unknown in children.

METHODS

We retrospectively analyzed the clinical characteristics of patients 1 month to 21 years of age who were admitted to the hospital with PIVH over a 7-year period. PIVH was defined as bleeding confined to the ventricular system without parenchymal or subarachnoid hemorrhage involvement.

RESULTS

Of 18 included patients, 55.6% were female, and mean age was 13.8 ± 6.0 years. The most common presenting symptoms were headache (77.8%) and vomiting (33.3%). In 15 patients (83.3%), known etiologies were diagnosed, including arteriovenous malformations (66.7%), moyamoya disease (11.1%), and aneurysms (5.6%). Idiopathic PIVH was the diagnosis in 3 patients (16.7%). Surgery was performed in 15 patients (83.3%), and 3 patients (16.7%) received conservative treatment. Four patients (28.6%) had an unfavorable outcome at discharge, and 3 patients (16.7%) had an unfavorable outcome at the 3-month follow-up. Higher Graeb score was associated with an unfavorable outcome in both short-term and long-term follow-up.

CONCLUSIONS

Arteriovenous malformations were diagnosed in most pediatric patients with PIVH. Specific surgical treatment of underlying etiologies should be required to increase clinical improvement. Children with a higher Graeb score at admission tended to have poor early and late outcomes.

Safety and efficacy of recanalization therapy in pediatric stroke: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Safety and efficacy of intravenous (IV) thrombolysis and endovascular therapy in children with acute ischemic stroke (AIS) are unknown to date. We aimed to review and synthesize currently available evidence on these acute recanalization therapies in pediatric stroke patients.

METHODS

We performed a systematic review and meta-analysis of all available data on safety and efficacy of acute treatment including thrombolysis and endovascular therapy in pediatric AIS patients aged <18 years. We searched the electronic databases Medline and Cochrane Library for eligible studies published from the earliest date available until August 31, 2016. Safety outcomes included intracerebral hemorrhage (ICH) post-treatment and in-hospital mortality. Efficacy outcomes included functional outcome 3-6 months after index stroke.

RESULTS

We identified 222 records, of which 3 studies with a total of 16,987 pediatric stroke patients met our eligibility criteria of whom 181 received IV thrombolysis. No data exists from randomized trials and no data is available on endovascular thrombectomy. Risk of any ICH was increased in children receiving thrombolysis (risk ratio = 3.48, 95%CI: 1.66-7.29; p = 0.001) compared with controls, with no evidence of heterogeneity (I² = 0%). None of the included studies reported complete data on symptomatic ICH. In-hospital mortality was similar between pediatric stroke patients treated with thrombolysis and controls (risk ratio = 1.44, 95%CI: 0.39-5.40; p = 0.586), with evidence of heterogeneity (I² = 62%). Efficacy of revascularization therapies could not be analyzed due to lack of outcome data.

CONCLUSIONS

Our analyses demonstrate a substantial lack of data on efficacy and safety of acute recanalization therapies in children with AIS.

PROSPERO REGISTRATION INFORMATION

URL: http://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42016047140.

Childhood Stroke: Awareness, Interest, and Knowledge Among the Pediatric Community

Objective: Acute childhood stroke is an emergency requiring a high level of awareness among first-line healthcare providers. This survey serves as an indicator of the awareness of, the interest in, and knowledge of childhood stroke of German pediatricians. Methods: Thousand six hundred and ninety-seven physicians of pediatric in- and outpatient facilities in Bavaria, Germany, were invited via email to an online-survey about childhood stroke. Results: The overall participation rate was 14%. Forty-six percent of participants considered a diagnosis of childhood stroke at least once during the past year, and 47% provide care for patients who have suffered childhood stroke. The acronym FAST (Face-Arm-Speech-Time-Test) was correctly cited in 27% of the questionnaires. Most commonly quoted symptoms of childhood stroke were hemiparesis (90%), speech disorder (58%), seizure (44%), headache (40%), and impaired consciousness (33%). Migraine (63%), seizure (39%), and infections of the brain (31%) were most frequently named as stroke mimics. Main diagnostic measures indicated were magnetic resonance imaging (MRI) (96%) and computer tomography (CT) (55%). Main therapeutic strategies were thrombolysis (80%), anticoagulation (41%), neuroprotective measures, and thrombectomies (15% each). Thirty-nine percent of participants had taken part in training sessions, 61% studied literature, 37% discussed with colleagues, and 25% performed internet research on childhood stroke. Ninety-three percent of participants approve skill enhancement, favoring training sessions (80%), publications (43%), and web based offers (35%). Consent for offering a flyer on the topic to caregivers in facilities was given in 49%. Conclusion: Childhood stroke constitutes a topic of clinical importance to pediatricians. Participants demonstrate a considerable level of comprehension concerning the subject, but room for improvement remains. A multi-modal approach encompassing an elaborate training program, regular educational publications in professional journals, and web based offers could reach a broad range of health care providers. Paired with a public adult and childhood stroke awareness campaign, these efforts could contribute to optimize the care for children suffering from stroke.

Pediatric Stroke Clinical Pathway Improves the Time to Diagnosis in an Emergency Department

BACKGROUND

Identified barriers to the diagnosis of pediatric stroke include delays in provider recognition and definitive neuroimaging (magnetic resonance imaging). Clinical pathways are recommended to address these barriers; yet few studies have evaluated their impact. Our aim is to describe the effect of a pediatric stroke clinical pathway on the diagnosis of stroke in patients presenting with focal neurological dysfunction to a pediatric emergency department.

METHODS

The pediatric stroke clinical pathway was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. Demographic and clinical data were collected for patients ultimately diagnosed with stroke using the pediatric stroke clinical pathway and compared with data collected on patients diagnosed with stroke before implementation of the pediatric stroke clinical pathway.

RESULTS

The pediatric stroke clinical pathway was activated for 36 patients. Stroke was diagnosed in 11 patients (33%), of whom 55% were male with a median age 11 ± 7 years. Focal deficits (82%) and headache (55%) were common presenting complaints. There was a significant improvement in the median time to magnetic resonance imaging from arrival to the emergency department (before implementation of the pediatric stroke clinical pathway: 17 hours [interquartile range 6, 22] versus after implementation of the pediatric stroke clinical pathway: four hours [interquartile range 3, 12]; P = 0.02).

CONCLUSIONS

The pediatric stroke clinical pathway improved time to definitive diagnosis and streamlined the care provided to children presenting to the pediatric emergency department with focal neurological dysfunction.