Pediatric Stroke Pathway Improves Time to Definitive Diagnosis

A pediatric stroke clinical pathway significantly improved time to definitive diagnosis while also streamlining the care provided to children presenting to the pediatric emergency department (ED) with focal neurological dysfunction.

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While more common in adults, the incidence of stroke in children is between 2 and 13 per 100,000, making it at least as common as pediatric brain tumors. These children are often discharged from acute care settings with neurological deficits, resulting in significant morbidity that leads to substantial health care expenses over the course of that patient’s life. Early intervention can help to minimize the physical and economic burden of the disease, but clinicians are often hampered by the nonspecific clinical presentation of pediatric stroke, which can delay definitive diagnosis.

In a study published in Pediatric Neurology, researchers led by Amy M Delarche, MBBS, Children’s Hospital of Michigan, described their experience implementing a pediatric stroke pathway and assessed its impact on the diagnosis of stroke in a pediatric ED.

Two cohorts of children were included in the study: those treated for stroke before the implementation of the pathway, and those treated for stroke after the implantation of the pathway. All patients were between the ages of 1 month and 18 years and admitted to the ED with neurological deficits. Demographic and clinical data, including presenting signs and symptoms, physical examination findings, imaging results, and hospital length of stay, were measured in both groups.

The pathways were activated in patients who presented to the ED with a positive stroke screen within 72 hours of symptom onset, defined as prior stroke, congenital heart disease, head trauma in the past week, and other factors often associated with stroke. Clinicians then alerted the anesthesia, critical care, neurology, and radiology departments to expedite imaging and admission to the hospital unit. Patients with sickle cell disease received early exchange transfusion followed by an MRI (magnetic resonance imaging) scan while patients without sickle cell received an urgent CT (computerized tomography) scan followed by MRI.

The pathway was initiated in a total of 36 patients, 11 of whom were diagnosed with stroke. Most (64%) had an ischemic stroke while 36% had a hemorrhagic stroke; focal deficits (82%) and headaches (55%) were the most common complaints among those who presented with either condition.

Time to MRI from arrival to the ED fell by more than half in patients who were treated on pathway (4 hours) vs those treated before the implementation of the pathway (17 hours). However, median length of stay in the pediatric ED and overall median hospital length of stay were unchanged before and after pathway implementation. There were no deaths in the post-pathway group; 2 patients died in the pre-pathway group. 

“Our study demonstrates that a standardized institutional protocol can significantly improve the time to a diagnosis of acute stroke among children presenting to a tertiary care pediatric ED with neurological deficits,” authors of the study concluded. 

However, they did also note that their study was limited to a single institution with a relatively small patient cohort. In addition, the pathway was activated based on the individual pediatric ED clinician’s suspicion of stroke, which may have resulted in over- or under-activation of the pathway in some cases.—Sean McGuire

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DeLaroche AM, Sivaswamy L, Farooqi A, Kannikeswaran N. Pediatric stroke clinical pathway improves the time to diagnosis in an emergency department [published online September 13, 2016] Pediatr Neurol. doi:10.1016/j.pediatrneurol.2016.09.005.