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Pediatric Acute Stroke Protocol Activation in a Children's Hospital Emergency Department
Travis R Ladner1, Jasia Mahdi1, Melissa C Gindville1
1From the Vanderbilt University School of Medicine (T.R.L., J.M.); Divisions of Pediatric Neurology (M.C.G., L.C.J.) and Pediatric Emergency Medicine (A.G., K.C.), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis School of Medicine, MO (J.M.); Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (Z.L.H.); Division of Pediatric Radiology, Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, TN (S.P.); and Division of Pediatric Emergency Medicine, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (T.J.A.).
Insights
Pediatric stroke alerts often indicate serious neurological conditions. Prompt evaluation in emergency departments is crucial, as 40% of pediatric brain attacks were confirmed strokes or other neurological emergencies.
Area of Science:
- Pediatric Neurology
- Emergency Medicine
- Neuroimaging
Background:
- Pediatric acute stroke teams are emerging as a critical component of emergency care.
- Understanding the diagnostic yield of stroke protocols in children is essential.
Purpose of the Study:
- To characterize the final diagnoses in children experiencing "brain attacks" under a pediatric acute stroke protocol.
- To describe the time intervals to neurological evaluation and neuroimaging in these pediatric patients.
Main Methods:
- Retrospective analysis of a quality improvement database and medical records.
- Inclusion of consecutive pediatric patients (≤20 years) with activated acute stroke protocol from April 2011 to October 2014.
- Defined protocol activation by rapid neurology resident evaluation and availability of urgent magnetic resonance imaging.
Main Results:
- 124 stroke alerts were analyzed; 30 confirmed strokes and 2 transient ischemic attacks.
- 37% of cases were healthy children; 14% had other neurological emergencies (meningitis/encephalitis, neoplasms).
- Complex migraine (17%) and seizure (15%) were common diagnoses. Median time to MRI was 94 minutes.
Conclusions:
- 24% of pediatric brain attacks were stroke, 2% transient ischemic attack, and 14% other neurological emergencies.
- 40% of pediatric patients presenting with brain attacks had a stroke or other serious neurological emergency.
- Highlights the necessity for rapid assessment and management of pediatric neurological emergencies.
Background And Purpose:
Pediatric acute stroke teams are a new phenomenon. We sought to characterize the final diagnoses of children with brain attacks in the emergency department where the pediatric acute stroke protocol was activated and to describe the time to neurological evaluation and neuroimaging.
Methods:
Clinical and demographic information was obtained from a quality improvement database and medical records for consecutive patients (age, ≤20 years) presenting to a single institution's pediatric emergency department where the acute stroke protocol was activated between April 2011 and October 2014. Stroke protocol activation means that a neurology resident evaluates the child within 15 minutes, and urgent magnetic resonance imaging is available.
Results:
There were 124 stroke alerts (age, 11.2±5.2 years; 63 boys/61 girls); 30 were confirmed strokes and 2 children had a transient ischemic attack. Forty-six of 124 (37%) cases were healthy children without any significant medical history. Nonstroke neurological emergencies were found in 17 children (14%); the majority were meningitis/encephalitis (n=5) or intracranial neoplasm (n=4). Other common final diagnoses were complex migraine (17%) and seizure (15%). All children except 1 had urgent neuroimaging. Magnetic resonance imaging was the first study in 76%. The median time from emergency department arrival to magnetic resonance imaging was 94 minutes (interquartile range, 49-151 minutes); the median time to computed tomography was 59 minutes (interquartile range, 40-112 minutes).
Conclusions:
Of pediatric brain attacks, 24% were stroke, 2% were transient ischemic attack, and 14% were other neurological emergencies. Together, 40% had a stroke or other neurological emergency, underscoring the need for prompt evaluation and management of children with brain attacks.
