Urgent computed tomography angiography in paediatric stroke
Romain C Briest1, Andrew K Cheung2, Tejaswi Kandula1,3
1Department of Neurology, Sydney Children's Hospital, Randwick, NSW, Australia.
Insights
Prompt diagnosis and rapid imaging are crucial for effective acute ischemic stroke (AIS) treatment in children. Computed tomography angiography (CTA) aids in timely interventions for large vessel occlusions, improving outcomes.
Area of Science:
- Pediatric Neurology
- Vascular Neurology
- Emergency Medicine
Background:
- Acute ischemic stroke (AIS) in children requires timely diagnosis and treatment.
- Clinical presentation of pediatric AIS can vary, influencing diagnostic speed.
- Effective delivery of acute therapies is essential to improve outcomes.
Purpose of the Study:
- To identify factors influencing the speed of diagnosis and delivery of acute therapies for pediatric AIS.
- To evaluate the role of imaging modalities in facilitating rapid treatment.
Main Methods:
- Prospective cohort study of children with suspected AIS.
- Retrospective analysis of children with confirmed AIS.
- Analysis of clinical features, imaging (CTA, MRA), and treatment interventions.
Main Results:
- Children presenting with symptoms other than sustained hemiparesis had slower diagnosis.
- Computed tomography angiography (CTA) facilitated quicker diagnosis and treatment compared to MRI/MRA.
- Arterial abnormalities were identified in 31/51 AIS patients, including large vessel occlusion, dissection, and moyamoya disease.
- 80% of AIS patients without arterial abnormalities were ineligible for thrombolysis, but showed good outcomes with supportive care.
Conclusions:
- Clinical presentation significantly impacts the recognition and diagnosis of AIS in children.
- CTA is effective in identifying large vessel occlusions and guiding thrombectomy and thrombolysis.
- Most childhood AIS without identifiable arterial abnormalities have favorable outcomes with supportive care.
Aim:
To improve delivery of acute therapies for acute ischaemic stroke (AIS).
Method:
We identified factors influencing the speed of diagnosis and delivery of acute therapies in a prospective cohort of 21 children with suspected AIS (eight with AIS, 13 stroke mimics) and explored them in a retrospective cohort with confirmed AIS.
Results:
Approximately half of the prospective and total AIS cohorts presented with acute, sustained hemiparesis, and were diagnosed relatively quickly. AIS was suspected and diagnosed more slowly in the half presenting with symptoms other than sustained hemiparesis. Thirty-one out of 51 patients with AIS (19 females, 32 males, mean age 8 years 6 months, SD 5 years 4 months) had arterial abnormalities identified by computed tomography angiography (CTA) or magnetic resonance angiography (MRA): 11 with large vessel occlusion, six with dissection, five with moyamoya disease, nine with other arteriopathies. Among these patients, those initially imaged with CTA were diagnosed more quickly than those with initial magnetic resonance imaging/angiography, which facilitated thrombectomy and thrombolytic therapy. Twenty out of 51 had AIS without arterial abnormalities on CTA or MRA: eight with lenticulostriate vasculopathy and 12 with other small-vessel AIS. Among these patients, 80% were ineligible for thrombolysis for reasons beyond delay to diagnosis, and all showed good outcomes with supportive treatments alone.
Interpretation:
Clinical features at presentation influence rapidity with which childhood AIS is suspected and diagnosed. Readily available CTA can direct thrombectomy in patients with large vessel occlusion and thrombolysis in most, but not all, eligible patients.
What This Paper Adds:
Children with acute ischaemic stroke (AIS) commonly present with symptoms other than sustained hemiparesis. Stroke is more slowly recognized in these patients, which limits potential therapies. Computed tomography angiography (CTA) accurately identifies AIS with large vessel occlusion, enabling timely endovascular thrombectomy. CTA is sufficient to direct thrombolytic therapy in most eligible children. Most childhood AIS without arterial abnormalities identified by CTA had good outcomes.
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