Pediatric Acute Stroke Readiness: A Multidisciplinary Challenge

Is your health care system pediatric stroke ready? If you are part of an adult stroke center, do your stroke care pathways address an adolescent or younger child with a possible stroke arriving at your emergency department? If you are at a children’s hospital, do you have a stroke care pathway? As recanalization therapies have been increasingly offered to children with acute arterial ischemic stroke, many hospitals have been caught off guard when such a child presents to them. Questions that often ensue: Has our hospital educated our frontline medical personnel about stroke in children, so that in children with sudden onset focal neurological deficits, stroke is on the differential? Does our hospital have a feasible, agreed upon neuroimaging protocol? Should this particular child be offered thrombolytics or thrombectomy? Will our pharmacy allow us to order thrombolytics for a child with a stroke? Will our endovascular surgeons offer thrombectomy to a child? Can our intensive care unit admit a child after an endovascular procedure? Where is the nearest hospital that will offer recanalization therapy to a child?

Because the evidence supporting recanalization therapies for pediatric stroke remains limited, the American Heart Association has published only a scientific statement, not guidelines, addressing stroke management in children.¹ Hence, to be pediatric stroke ready, hospital systems need to review the evidence and develop preestablished pathways that reflect both available resources and local consensus on what should or should not be offered to a child with a stroke.

The article by Tudorache et al² in this issue of Stroke adds to the body of literature that stroke centers and children’s hospitals should consider in their process of becoming pediatric stroke ready. It also demonstrates the importance of prehospital providers in systems of care for pediatric stroke. The article focuses on determinants of timely access to recanalization treatments for children with arterial ischemic stroke.² The authors utilized data from the Kid Clot study, a multicenter, national retrospective study of children from 28 days to 18 years of age residing in mainland France or a French territory at stroke onset, between 2015 and 2018, who received recanalization therapy for arterial ischemic stroke. In the current article, the authors analyzed data on 68 children with AIS who received either intravenous thrombolysis, mechanic thrombectomy, or both therapies. Factors such as prehospital concern for stroke, that is, dispatching emergency medical services for a potential stroke, direct presentation and admission to a tertiary care center versus need for transfer to a tertiary center, and management in a pediatric versus an adult unit were evaluated. They then examined how these variables impacted time to treatment and clinical outcomes for these children.

The most important factor that emerged was prehospital concern for stroke, which was associated with more rapid recanalization therapy and improved neurological outcome. Of note, children identified via prehospital triage were older—median age 13.5 versus 8.5 years—although the P value for this age difference was not significant, P=0.129. Direct presentation to tertiary center did not result in more rapid recanalization therapy than children who required transfer to a tertiary center. Presenting to an adult rather than a pediatric unit resulted in slightly faster care. Limitations of the study include: the relatively small sample size, the retrospective nature of the study, and the somewhat limited generalizability given that the distance and time from nontertiary to tertiary centers in France or overseas French territories may be less significant than in a country with larger land mass like Canada, Australia or the United States.

Regardless, this work suggests that it may not be enough for stroke centers and children’s hospitals to be pediatric stroke ready. Raising awareness of childhood stroke among prehospital emergency medical providers is of the utmost importance. In the current study, children that arrived at hospitals already identified as potentially having a stroke via prehospital triage were treated more quickly with recanalization therapies. Health systems may worry that if pediatric stroke awareness improves with time, too many children may be transported and urgently imaged for a possible stroke. Indeed, stroke mimics are more common than strokes in children, and studies at tertiary children’s medical centers, presumably with greater stroke expertise, have found that for every 5 pediatric code stroke activations on average there is only 1 stroke diagnosis.^3,4 However, many of those stroke codes lead to other actionable neurological diagnoses. The fact that children with stroke mimics are often quite ill supports the importance of rapid evaluation.

Fortunately, another recent publication in Stroke suggests a simple way for both prehospital providers and for in-hospital non-neurologist medical staff to detect candidates for pediatric acute stroke treatment. The recently described pediatric adaptation of the Rapid Arterial Occlusion Evaluation scale,⁵ which scores 5 items (facial palsy, 0–2; arm motor function, 0–2; leg motor function, 0–2; head/gaze deviation, 0–1; and aphasia or agnosia, 0–2), has good sensitivity and specificity in detecting large vessel occlusion in adults and is promising in children. Using this simple scale in 50 children with and without stroke, prehospital/emergency staff and child neurologists in Catalonia agreed fully regarding 82% of children and pediatric Rapid Arterial Occlusion Evaluation scores were significantly higher in patients with large vessel occlusion (6.5; interquartile range, 6–7) than with other etiologies. The pediatric Rapid Arterial Occlusion Evaluation scale showed good interrater reliability and correlation with the Pediatric National Institutes of Health Stroke Scale.⁶

Improving pediatric stroke readiness both at adult and pediatric medical centers remains an important yet unresolved issue, and pediatric stroke awareness is the critical first step. Improving recognition of stroke in children is often a local issue, involving education that occurs 1 region or 1 hospital at a time, yet feasible and scalable educational interventions are lacking. The Tudorache article refers to prehospital triage as a key determinant of time-to-thrombolysis or thrombectomy but does not describe in detail the steps of that process or potential improvements. Presumably, we should be educating emergency services dispatchers and emergency medical technicians about pediatric stroke. What about healthcare providers in hospital emergency departments who take calls from prehospital providers? Further, because a child must present for medical care rapidly, stroke education for school nurses and parents of children with known medical conditions placing them at high-risk of stroke seems important.

International collaborations can realistically strive to raise awareness and develop pediatric stroke readiness resources that can be modified for use in the local context. The International Pediatric Stroke Organization aims to advance the understanding, care, and outcomes of children with stroke. One key International Pediatric Stroke Organization objective is to increase the readiness of hospitals to identify children with stroke and care for them. KidClot emphasizes that this work must extend to prehospital triage, educating and developing protocols to rapidly identify children with stroke. For the last decade, many children’s hospitals worldwide have slowly developed care pathways for pediatric stroke. International Pediatric Stroke Organization has >400 members from >20 countries sharing knowledge and building consensus around the treatment of pediatric neurovascular diseases, but most work in children’s hospitals, and resources, systems of care and the availability of neurologists varies widely. What does pediatric stroke readiness look like around the world? Readiness can translate to education of frontline medical providers to recognize children with stroke. Even if acute interventions such as thrombectomy are not available due to patient or center factors, supportive care can be provided, and secondary stroke prevention with aspirin or other appropriate medications can be initiated. One example is the special population of children with sickle cell disease in sub-Saharan Africa with thousands of children at high-risk of stroke in predominantly low-resource settings—where readily available and affordable oral hydroxyurea will reduce the risk of further stroke.⁷

The next step is for adult stroke centers (primary and comprehensive stroke centers in the US and similar centers around the world) to commit to becoming pediatric stroke ready and meaningfully improve care for children with stroke. Accreditation bodies for these stroke centers, like the Joint Commission in the United States, should formally consider requirements related to pediatric stroke. Readiness will involve fostering regional networks of triage and referral for children with possible stroke that involve partnerships across prehospital emergency medical systems, pediatric medical centers, and adult stroke centers. Adult stroke systems are expert at rapid identification and triage of adults with stroke; extending lessons learned and understanding what may or may not apply to children with stroke will be critical.