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ACR Appropriateness Criteria® Cerebrovascular Disease-Child
, Richard L Robertson1, Susan Palasis2
1Boston Children's Hospital, Boston, Massachusetts.
Insights
Pediatric stroke, though uncommon, is a serious cause of child illness and death. Prompt neuroimaging is crucial for accurate diagnosis, distinguishing true strokes from mimics.
Area of Science:
- Pediatric neurology
- Neuroradiology
- Clinical guidelines
Background:
- Pediatric stroke is an under-recognized cause of child morbidity and mortality, presenting with diverse symptoms.
- Stroke mimics, such as complicated migraine and seizures, are common and can delay diagnosis of true pediatric stroke.
- Accurate diagnosis is challenging due to symptom overlap and numerous potential causes of stroke and stroke mimics.
Framework:
- The American College of Radiology Appropriateness Criteria provide evidence-based guidelines for imaging in pediatric stroke.
- Guidelines are developed through rigorous analysis of medical literature and expert consensus.
- Methodologies like RAND/UCLA and GRADE ensure a systematic approach to evaluating imaging appropriateness.
Implementation:
- Imaging is critical for assessing children with acute neurological deficits suggestive of stroke.
- Guidelines aid clinicians in selecting appropriate imaging modalities for suspected pediatric stroke.
- Expert opinion supplements evidence where data is limited, guiding diagnostic decisions.
Implications:
- Timely and accurate diagnosis of pediatric stroke improves patient outcomes.
- Appropriate imaging strategies reduce diagnostic delays and misdiagnosis.
- Evidence-based guidelines enhance the quality of care for children with neurological emergencies.
Abstract:
Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
