Results

Discussion

References

Discussion

Pediatric stroke protocol implementation at our center improved over the 7-year period. Protocol utilization by the ED and particularly by inpatient providers increased over time. Although the frequency of confirmed stroke or other neurologic emergency for which rapid neurologic evaluation was appropriate did not differ significantly over time (37% in period 1 and 39% in period 2), indicators of successful pediatric acute stroke protocol implementation, including the use and documentation of the PedNIHSS to assess stroke severity, increased. MRI as first neuroimaging study for most children with stroke-like symptoms also increased over time. MRI is the preferred first-line imaging in pediatric stroke, because CT is unable to differentiate common stroke mimics and has been reported to miss as many as 47%-84% of ischemic strokes in children that are later confirmed by MRI. Supportive care and IV fluids were provided to all children with acute stroke. In addition, the vast majority of children with ischemic stroke for whom secondary prevention with antithrombotic medication was indicated were started and discharged to home on these medications. Most published accounts of pediatric stroke protocol utilization have not provided an assessment of children with stroke with a delayed or missed diagnosis. Only 1 in 5 children for whom a pediatric stroke alert was activated had a final diagnosis of ischemic or hemorrhagic stroke. We searched carefully for children with delayed diagnosis of stroke, because the number of stroke mimics is significant. With radiology text searches, we were not able to identify any missed ischemic strokes. We did find 8 children (2%) for whom a pediatric stroke alert was not activated for >60 minutes after arrival to the hospital or after symptoms were noted for those already in the hospital. In these cases, pediatric neurology was frequently consulted, and the neurology team activated the stroke protocol after examining the child. It was difficult to discern retrospectively whether acute stroke was not recognized by the primary team or whether there was lack of familiarity with the pediatric stroke protocol and so a neurology consult was called instead of a stroke alert.Pediatric stroke protocol implementation at our center improved over the 7-year period. Protocol utilization by the ED and particularly by inpatient providers increased over time. Although the frequency of confirmed stroke or other neurologic emergency for which rapid neurologic evaluation was appropriate did not differ significantly over time (37% in period 1 and 39% in period 2), indicators of successful pediatric acute stroke protocol implementation, including the use and documentation of the PedNIHSS to assess stroke severity, increased. MRI as first neuroimaging study for most children with stroke-like symptoms also increased over time. MRI is the preferred first-line imaging in pediatric stroke, because CT is unable to differentiate common stroke mimics and has been reported to miss as many as 47%-84% of ischemic strokes in children that are later confirmed by MRI.13,14 Supportive care and IV fluids were provided to all children with acute stroke. In addition, the vast majority of children with ischemic stroke for whom secondary prevention with antithrombotic medication was indicated were started and discharged to home on these medications. Most published accounts of pediatric stroke protocol utilization have not provided an assessment of children with stroke with a delayed or missed diagnosis.5-7 Only 1 in 5 children for whom a pediatric stroke alert was activated had a final diagnosis of ischemic or hemorrhagic stroke. We searched carefully for children with delayed diagnosis of stroke, because the number of stroke mimics is significant. With radiology text searches, we were not able to identify any missed ischemic strokes. We did find 8 children (2%) for whom a pediatric stroke alert was not activated for >60 minutes after arrival to the hospital or after symptoms were noted for those already in the hospital. In these cases, pediatric neurology was frequently consulted, and the neurology team activated the stroke protocol after examining the child. It was difficult to discern retrospectively whether acute stroke was not recognized by the primary team or whether there was lack of familiarity with the pediatric stroke protocol and so a neurology consult was called instead of a stroke alert.