In Children, Stroke Diagnosis May Be Delayed

Laurie Barclay, MD

February 24, 2011

February 24, 2011 — In children, stroke diagnosis may be delayed, according to the results of a retrospective descriptive case series reported online February 11 in the Annals of Emergency Medicine.

"Stroke in children is rare, but it does exist," said lead author Franz Babl, MD, MPH, from Royal Children's Hospital and Murdoch Children's Research Institute in Melbourne, Australia, in a news release. "Stroke patients in our study had previously been generally healthy, unlike their adult counterparts. Because pediatric stroke is so rare, it's not the first thing we look for. Stroke symptoms in children are frequently attributed to other, more common problems, such as migraine, seizures or encephalitis."

The investigators described the presentation at a single-center tertiary emergency department during a 5-year period of consecutive patients aged 1 month to younger than 18 years with radiologically confirmed acute ischemic and hemorrhagic stroke. For hemorrhagic stroke (n = 31), patients were identified by medical record search with International Classification of Diseases, 10th Revision, codes. Those with acute ischemic stroke (n = 50) were identified from the hospital stroke registry. The investigators reviewed signs, symptoms, and initial management.

Mean patient age was 8.7 ± 5.2 years, 51% were boys, and 56% were previously healthy. For acute ischemic stroke, median time from symptom onset to emergency department presentation was 21 hours (interquartile range, 6 - 48 hours) vs 12 hours (interquartile range, 4 - 72 hours) for hemorrhagic stroke.

Presenting symptoms for acute ischemic stroke were focal limb weakness in 64% (95% confidence interval [CI], 49% - 77%) of patients, facial weakness in 60% (95% CI, 45% - 73%), and speech disturbance in 46% (95% CI, 31% - 60%). Vomiting and altered mental status were uncommon presentations in acute ischemic stroke. The Glasgow Coma Scale score was 14 or greater in 86% of patients with acute ischemic stroke (95% CI, 73% - 94%), and 88% presented with at least 1 focal neurologic sign (95% CI, 73% - 98%).

Of children with hemorrhagic stroke, 73% presented with a headache (95% CI, 54% - 87%), 58% with vomiting (95% CI, 40% - 75%), and 48% with altered mental status (95% CI, 30% - 67%). The Glasgow Coma Scale score in children with hemorrhagic stroke was less than 14 in 38% and less than 8 in 19% (95% CI, 7% - 37%). Focal limb weakness, facial weakness, or slurred speech occurred in less than one third of children.

Although 19% of patients with hemorrhagic stroke were intubated in the emergency department and admitted to the intensive care unit, none of the children with acute ischemic stroke were intubated in the emergency department, and only 4% were admitted to the intensive care unit.

A computed tomography (CT) scan identified all cases of hemorrhagic stroke but only half of acute ischemic stroke cases, suggesting that magnetic resonance imaging may be preferred in the diagnosis of ischemic stroke.

"The symptoms and signs of acute ischemic and hemorrhagic stroke are similar in adults and children, but in children stroke is not considered early enough and patients do not receive brain imaging early enough," Dr. Babl said. "Rapid recognition, response and treatment of children with stroke will start with the development of pediatric brain attack protocols in the emergency department and pre-hospital setting. This study is a first step toward achieving that goal."

Limitations of this study include retrospective design, data extraction from medical records, and lack of generalizability beyond the setting of a tertiary pediatric referral emergency department.

"The development of a brain attack clinical pathway may improve identification of stroke patients and allow differentiation of stroke from other acute neurologic conditions," the study authors conclude. "It may also aid rapid triage, medical assessment, and neuroimaging, potentially increasing the feasibility of thrombolytic therapy for ischemic stroke and rapid neurosurgical intervention in children for hemorrhagic stroke."

Grant support from the National Stroke Foundation, Melbourne, Australia, and the Murdoch Children's Research Institute, Melbourne, Australia, supported this study. The study authors were required to report any financial disclosures to the Annals of Emergency Medicine.

Ann Emerg Med. Published online February 11, 2011. Abstract

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