The Positive Predictive Value of Pediatric Stroke Diagnoses in Administrative Data: A Retrospective Validation Study

Background

This retrospective cohort study aimed to examine the positive predictive value (PPV) of pediatric stroke diagnoses in the Danish National Registry of Patients (DNRP) and the impact of different stroke definitions on the PPV.

Methods

We included children registered with a stroke or stroke-related diagnosis in the DNRP between January 2017 through December 2020. Two assessors reviewed medical records and validated cases according to the American Heart and American Stroke Association (AHA/ASA) stroke definition. The level of interrater agreement was examined using kappa statistics. Validation by the AHA/ASA definition was compared with validation according to the definition in the International Classification of Disease 11th version (ICD-11) and the World Health Organization's definition.

Results

Stroke was confirmed in 120 of 309 included children, yielding an overall PPV of 0.39 (95% CI: 0.33-0.45). PPV varied across stroke subtypes from 0.83 (95% CI: 0.71-0.92) for ischemic stroke (AIS), 0.57 (95% CI: 0.37-0.76) for unspecified stroke, 0.42 (95% CI: 0.33-0.52) for intracerebral hemorrhage (ICH) to 0.31 (95% CI: 0.55-0.98) and 0.07 (95% CI: 0.01-0.22) for cerebral venous thrombosis and subarachnoid hemorrhage (SAH), respectively. Most non-confirmed ICH and SAH diagnoses were in children with traumatic intracranial hemorrhages (36 and 66% respectively). Among 70 confirmed AIS cases, 25 (36%) were identified in non-AIS code groups. PPV varied significantly across stroke definitions with the highest for the AHA/ASA definition (PPV = 0.39, 95% CI: 0.34-0.45) and the lowest for the WHO definition (PPV = 0.29, 95% CI: 0.24-0.34). Correspondingly, the incidence of pediatric AIS per 100.000 person-years changed from 1.5 for the AHA/ASA definition to 1.2 for ICD-11 and 1.0 for the WHO-definition. The overall interrater agreement was considered excellent (κ=0.85).

Conclusion

After validation, stroke was confirmed in only half of the children registered in the DNRP with a stroke-specific diagnosis. Non-validated administrative data should be used with caution in pediatric stroke research. Pediatric stroke incidence rates may vary markedly depending on which stroke definition is used.

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.

Predictive Value of Pediatric Stroke Diagnoses in Administrative Data: A Systematic Literature Review

BACKGROUND AND AIM

Administrative healthcare data are frequently used for studying incidence, prevalence, risk factors, and outcome of pediatric stroke. However, the accuracy of these data sources is uncertain. The aim of this study was to systematically analyze published data on the positive predictive value (PPV) and sensitivity of diagnoses used to identify pediatric stroke patients in administrative data.

METHODS

This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We searched PubMed and Embase for studies, published in year 2000 or later, describing the PPV or sensitivity of diagnoses used to identify children with stroke in administrative data. The search was performed on June 9, 2022. Studies written in other languages than English, with less than 30 participants, and conference abstracts were excluded.

RESULTS

Eight studies were included after full-text review from 2,475 potentially eligible records. These included 3,137 children. All studies reported data from high-income countries. Reported PPVs varied considerably across studies and stroke subtypes: acute ischemic stroke, range 0.27-0.89; cerebral venous thrombosis, range 0.45-0.72; spontaneous subarachnoid hemorrhage, range 0.52-0.83; and spontaneous intracerebral hemorrhage, range 0.62-0.66. One study examined sensitivity of an ICD-9 search compared to a radiology report search and found that the ICD search had poor sensitivity (33%).

CONCLUSION

Caution is recommended in the use and interpretation of nonvalidated administrative data for pediatric stroke. Data on the PPV and sensitivity of pediatric stroke diagnoses in administrative data remain limited and are only available from high-income countries.

[Challenges and advances in paediatric arterial ischaemic stroke]

Neurological sequelae occur in more than 50% of children with arterial ischemic stroke. Early recognition and treatment are essential in improving outcome. However, diagnostic delay in paediatric stroke often extends beyond 24 hours, and children rarely access hyperacute recanalisation therapies. This review describes clinical presentations, risk factors and treatment of paediatric ischaemic stroke. Additionally, we share our experience from a systematic paediatric stroke pathway implemented in Eastern Denmark since 2017.