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A pediatric institutional acute stroke protocol improves timely access to stroke treatment
Melissa Shack1, Andrea Andrade2, Priyanka P Shah-Basak3
1Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
Insights
Implementing an acute stroke protocol (ASP) in children accelerated treatment times and improved diagnosis for mild strokes. The protocol increased MRI use, enhancing diagnostic accuracy for pediatric stroke patients.
Area of Science:
- Pediatric Neurology
- Stroke Medicine
- Healthcare Protocol Implementation
Background:
- Pediatric stroke diagnosis and treatment can be complex and time-consuming.
- Standardized protocols are essential for optimizing care in acute neurological conditions.
Purpose of the Study:
- To evaluate the impact of an institutional acute stroke protocol (ASP) on the diagnosis and secondary treatment of pediatric stroke.
- To assess changes in diagnostic imaging and time-to-treatment following ASP implementation.
Main Methods:
- A retrospective comparison of pediatric arterial ischemic stroke cases before (1992-2004) and after (2005-2012) the initiation of an ASP.
- Analysis of time-to-diagnosis, mode of diagnostic imaging (CT vs. MRI), and time-to-antithrombotic medication.
Main Results:
- While overall time-to-diagnosis remained similar, mild pediatric strokes showed significantly faster diagnosis post-protocol (12.1 vs. 36.3 hours).
- Magnetic resonance imaging (MRI) became the preferred initial diagnostic modality more frequently post-protocol (25% vs. 1.4%), demonstrating higher accuracy than initial CT.
- The proportion of children receiving antithrombotic medication within 24 hours significantly increased from 36% pre-protocol to 83% post-protocol.
Conclusions:
- A pediatric acute stroke protocol effectively accelerated time-to-treatment and improved diagnostic timeliness for subtle strokes.
- The protocol led to increased utilization of MRI, a more accurate initial diagnostic tool, and reduced reliance on CT.
- Optimized ASPs are crucial for facilitating timely diagnosis and management of acute pediatric stroke.
Aim:
We aimed to evaluate whether an institutional acute stroke protocol (ASP) could accelerate the diagnosis and secondary treatment of pediatric stroke.
Method:
We initiated an ASP in 2005. We compared 209 children (125 males, 84 females; median age 4.8y, interquartile range [IQR] 1.2-9.3y, range 0.09-17.7y) diagnosed with arterial ischemic stroke 'pre-protocol' (1992-2004) to 112 children (60 males, 52 females; median age 5.8y, IQR 1.0-11.4y, range 0.08-17.7y) diagnosed 'post-protocol' (2005-2012) for time-to-diagnosis, mode of diagnostic imaging, and time-to-treatment with antithrombotic medication (aspirin or anticoagulants).
Results:
Overall, the interval from symptom onset to diagnosis was similar post-protocol compared to pre-protocol (20.3 vs 22.7h; p=0.109), although mild strokes (Pediatric National Institute of Health Stroke Scale [PedNIHSS] 0-4), were diagnosed faster post-protocol (12.1 vs 36.3h; p=0.003). Magnetic resonance imaging (MRI) was the initial diagnostic modality more often post-protocol (25% vs 1.4%; p<0.001). Initial MRI was more accurate for diagnosing stroke than initial CT (100% vs 47%; p<0.001) with similar time-to-diagnosis. The proportion of children receiving antithrombotic medication within 24 hours doubled in the post-protocol period (83% vs 36%; p<0.001).
Interpretation:
A pediatric ASP accelerated time-to-treatment, time-to-diagnosis in children with subtle strokes, and increased MRI as initial imaging, reducing the need for computed tomography. Implementing optimized ASPs can facilitate more timely access to diagnosis and management of children with acute stroke.