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Published on: January 15, 2017
Accuracy and Reliability of Stroke Diagnosis in the Pediatric Emergency Department
Mark T Mackay1, Adriana Yock-Corrales2, Leonid Churilov2
1From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.). mark.mackay@rch.org.au.
Insights
Pediatric emergency physicians accurately diagnose childhood stroke (62% sensitivity, 98% specificity) but require tools for other neurological conditions. Diagnostic reliability varies significantly across different brain attack symptoms.
Area of Science:
- Pediatric Neurology
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Accurate diagnosis in the emergency department (ED) is crucial for timely acute stroke interventions.
- Pediatric stroke and other conditions presenting with brain attack symptoms require precise clinical diagnosis.
Purpose of the Study:
- To evaluate the accuracy and reliability of diagnoses made by pediatric emergency department (ED) physicians for childhood stroke.
- To assess diagnostic performance for other conditions presenting with brain attack symptoms.
Main Methods:
- Prospective study of children (1 month to 18 years) with focal neurological deficits presenting to the ED.
- Determined accuracy (sensitivity, specificity, ROC curves) and interrater agreement (κ) between ED physician and final neurological diagnoses.
Main Results:
- The most common diagnoses included migraine (84), first seizure (48), Bell's palsy (29), stroke (21), and conversion disorders (18).
- ED physician stroke diagnosis sensitivity was 62% and specificity 98% (ROC, 0.8). Inter-rater agreement for stroke was substantial (κ=0.61).
- Diagnostic accuracy was highest for Bell's palsy and lowest for central nervous system demyelination and cerebellitis.
Conclusions:
- Pediatric ED physician diagnostic accuracy and reliability vary considerably for disorders presenting with brain attack symptoms.
- Clinical recognition tools are needed to aid pediatric ED physicians in diagnosing stroke and other serious neurological disorders.
Background And Purpose:
Access to acute stroke interventions in the emergency department (ED) relies on correct clinical diagnosis. Our aims were to determine the accuracy and reliability of pediatric ED physician diagnosis of childhood stroke and other conditions presenting with brain attack symptoms.
Methods:
Prospective study of consecutive children aged 1 month to 18 years presenting to the ED from June 2009 to December 2010 with focal neurological deficits. Accuracy (sensitivity, specificity, and receiver operator characteristic curves [ROCs]) and interrater agreement (κ) were determined, between ED physician diagnoses, as recorded in the electronic hospital administrative software system, and final neurological diagnosis, after completion of diagnostic work-up.
Results:
Two-hundred eighty-seven children with 301 consecutive presentations were recruited. The most common final brain attack diagnoses included migraine in 84 children, first seizure in 48, Bell's palsy in 29, stroke in 21, and conversion disorders in 18 children. Sensitivity of ED physician stroke diagnosis was 62%, and specificity was 98% (ROC, 0.8). Inter-rater agreement for ED physician and final stroke diagnosis was substantial (κ=0.61). ED physician diagnostic accuracy and reliability was highest for Bell's palsy (ROC=0.98; κ=0.96), and lowest for central nervous system demyelination (ROC=0.5; κ=-0.01) and cerebellitis (ROC=0.50; κ=0.50).
Conclusions:
ED physician diagnostic accuracy and reliability varies considerably across disorders presenting with brain attack symptoms. Clinical recognition tools are required to assist pediatric ED physicians with diagnosis of stroke and other serious neurological disorders.
