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Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals
Maria Gladkikh1, Hugh J McMillan1,2, Andrea Andrade3
1University of Ottawa, Faculty of Medicine, Ottawa, ON, Canada.
Insights
Canadian pediatric stroke protocols show variation in treatment guidelines for acute arterial ischemic stroke (AIS). Establishing national consensus on IV-tPA and endovascular treatments is crucial for standardized AIS management.
Area of Science:
- Pediatric Neurology
- Stroke Management
- Clinical Pathways
Background:
- Childhood acute arterial ischemic stroke (AIS) diagnosis is often delayed, impacting treatment efficacy.
- Pediatric stroke pathways are essential for expediting diagnosis and management of AIS in children.
Purpose of the Study:
- To analyze similarities and differences in Canadian pediatric stroke protocols.
- To identify opportunities for optimizing AIS management through protocol standardization.
Main Methods:
- Neurologists from all 16 Canadian pediatric hospitals were surveyed regarding AIS management.
- Established protocols were systematically analyzed for variations across eight key domains.
Main Results:
- Only 44% of centers have established AIS protocols; two are developing them, and seven lack formal protocols.
- Significant variations exist in IV-tissue plasminogen activator (tPA) dosage, age cut-offs, exclusion criteria, neuroimaging choices, intra-arterial tPA use, and mechanical thrombectomy timeframes.
Conclusions:
- Despite progress, considerable heterogeneity in AIS management protocols persists across Canadian pediatric hospitals.
- Development of Canadian expert consensus on IV-tPA and endovascular treatments is recommended to standardize AIS protocols nationwide.
Background:
Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management.
Methods:
We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains.
Results:
Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75-0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2).
Conclusions:
Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.
