Tracking rapid response for stroke, TIA in children

In 40 percent of the cases when an emergency department (ED) physician at a pediatric hospital activated a stroke alert, the child ended up having a stroke, transient ischemic attack (TIA) or another neurological emergency, according to an analysis at one medical center.

Researchers Lori Jordan, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues said the results stressed the need for timely evaluation and management of children presenting with signs of a neurological emergency. Their findings were published online July 2 in Stroke.

In 2011, the children's hospital at Vanderbilt created a pediatric stroke team that included members from pediatric emergency medicine, critical care medicine, radiology and neurology. More than 50,000 children visit Vanderbilt’s ED each year.

For the current study, researchers examined children who arrived at the ED and had a pediatric acute stroke protocol activated between April 2011 and October 2014. At Vanderbilt, doctors activate a stroke alert when children present to the ED within 48 hours of signs and symptoms of TIA or acute stroke.

During the study period, there were 124 first-time stroke alerts in 63 boys and 61 girls. Of these, 30 children had stroke, two had TIA and 17 had nonstroke neurological emergencies. The most common signs and symptoms were hemiparesis/weakness (65 percent of children), altered mental status (44 percent) and headache (37 percent).

The median time from ED arrival to stroke alert activation was 17 minutes. The median time from symptom onset to presentation was 2.1 hours, including 5.2 hours in the children with stroke and 1.7 hours in children with other diagnoses. The median symptom onset to presentation was 9.8 hours in children with ischemic stroke and 2.9 hours in children with hemorrhagic stroke.

All but one child underwent neuroimaging. In 76 percent of the cases, doctors first gave the children an MRI. The median time from when children arrived at the ED to when they underwent an MRI was 94 minutes. If they first underwent CT, the median time was 59 minutes. The median time to first scan for any scan was 79 minutes.

The researchers cited a few study limitations, including that times were only documented for approximately half of the patients. In addition, stroke alerts are activated at Vanderbilt for children presenting within 48 hours, whereas other centers only activate stroke alerts within four to six hours.

They also noted for adults with ischemic stroke, the only interventions that improve outcomes are tissue-type plasminogen activator administration, endovascular thrombectomy and dedicated stroke centers that provide acute, supportive care.

“These interventions also may affect the outcomes of children with acute stroke,” they wrote. “Thus, early diagnosis of stroke in these young patients is imperative.”