Belinda Stojanovski

Arterial ischemic stroke in children with cardiac disease

Objective: To describe the spectrum of cardiac disorders, timing in relation to interventional procedures, and outcome in children with cardiac disease and arterial ischemic stroke (AIS). Methods: Children younger than 18 years with cardiac disease and radiologically confirmed AIS admitted to the Royal Childrens Hospital Melbourne between 1993 and 2010 were retrospectively identified using ICD-9 and ICD-10 searches. Results: Seventy-six children with cardiac disease and radiologically confirmed AIS were identified with the median age at diagnosis of 5 months (interquartile range 0–58). Cardiac lesions included cyanotic congenital heart disease (CHD) in 42 (55%), acyanotic heart disease in 24 (29%), cardiomyopathies/myocarditis in 6 (8%), infective endocarditis in 3 (4%), and primary arrhythmias in 3 (4%). Stroke occurred following cardiac procedures in 52 patients (68%): 41 post cardiac surgery (4.6 strokes per 1,000 surgical procedures) and 11 post cardiac catheterization (1.7 strokes per 1,000 catheterizations). The median time from procedure to diagnosis of stroke was 3 days (interquartile range 2–7), with 68% (95% confidence interval 58%–79%) of strokes estimated to occur within the periprocedural period. Prevalence of periprocedural stroke varied by diagnostic category, but was most common in patients with cyanotic CHD undergoing palliative surgery (22/2,256, 1%) (p < 0.005). There were 3 AIS-related deaths, and 54 survivors (84%) had persisting neurologic deficits. Conclusions: Infants with cyanotic CHD were most frequently affected by AIS during the periprocedural period. Prospective cohort studies are required to determine effective primary and secondary prevention strategies.

Focal Cerebral Arteriopathy: Do Steroids Improve Outcome?

Background and Purpose— Focal cerebral arteriopathy accounts for up to 35% of arterial ischemic stroke (AIS) in children and is the most important predictor of stroke recurrence. The study objective was to compare outcomes for children with focal cerebral arteriopathy treated with combined corticosteroid antithrombotic treatment (CAT) to those receiving antithrombotic treatment (AT) alone. Methods— This multicenter retrospective Swiss/Australian cohort study analyzed consecutive children, aged 1 month to 18 years, presenting with first AIS because of a focal cerebral arteriopathy from 2000 to 2014. Children with CAT were compared with those treated with AT. Primary outcome was the presence of neurological deficits at 6 months post–AIS as measured by the Pediatric Stroke Outcome Measure. Secondary outcomes included resolution of stenosis and stroke recurrence. Analysis of covariance was used to adjust for potential confounders (baseline pediatric National Institute of Health Stroke Scale and concomitant acyclovir use). Results— A total of 73 children (51% males) were identified, 21 (29%) of whom received CAT. Mean (SD) age at stroke for the entire group was 7.9 years (4.7). Median (interquartile range) pediatric National Institute of Health Stroke Scale was 3 (2.0–8.0) in the CAT group and 5 (3.0–9.0) in the AT group (P=0.098). Median (interquartile range) Pediatric Stroke Outcome Measure 6 months post-AIS was 0.5 (0–1.5) in the CAT group compared with 1.0 (0.5–2.0) in the AT group (P=0.035), the finding was sustained after adjusting for potential confounders. Complete resolution of stenosis at last MRI was noted in 17 (81%) in the CAT group compared with 24 (59%) in the AT group (P=0.197). Stroke recurrence occurred in 1 patient in each group. Conclusions— Corticosteroid treatment may provide additional benefit over AT for improved neurological outcome in childhood AIS because of focal cerebral arteriopathy. Larger prospective studies are warranted to further investigate these differences and understand mechanisms by which steroids modify outcome.

Parental Care–Seeking Behavior and Prehospital Timelines of Care in Childhood Arterial Ischemic Stroke

Background and Purpose— Taking appropriate action in the prehospital setting is important for rapid stroke diagnosis in adults. Data are lacking for children. We aimed to describe parental care–seeking behavior and prehospital timelines of care in childhood arterial ischemic stroke. Methods— A structured questionnaire was developed, using value-focused event-driven conceptual modeling techniques, to interview parents of children presenting to the emergency department with arterial ischemic stroke from 2008 to 2014. Results— Twenty-five parents (median age 41 years, interquartile range 36–45) were interviewed. Twenty-four children were awake, and 1 child was asleep at stroke onset; 23 had sudden onset symptoms. Location at stroke onset included home (72%), school (8%), or other setting (20%). Carergivers present included parent (76%), another child (8%), teacher (4%), or alone (8%). Eighty-four percent of parents thought symptoms were serious, and 83% thought immediate action was required, but only 48% considered the possibility of stroke. Initial actions included calling an ambulance (36%), wait and see (24%), calling a general practitioner (16%) or family member (8%), and driving to the emergency department or family physician (both 8%). Median time from onset to emergency department arrival was 76 minutes (interquartile range 53–187), being shorter for ambulance-transported patients. Conclusions— Stroke recognition and care-seeking behavior are suboptimal, with less than half the parents considering stroke or calling an ambulance. Initiatives are required to educate parents about appropriate actions to facilitate time-critical interventions.

Prehospital Emergency Care in Childhood Arterial Ischemic Stroke

Background and Purpose— Immediately calling an ambulance is the key factor in reducing time to hospital presentation for adult stroke. Little is known about prehospital care in childhood arterial ischemic stroke (AIS). We aimed to determine emergency medical services call-taker and paramedic diagnostic sensitivity and to describe timelines of care in childhood AIS. Methods— This is a retrospective study of ambulance-transported children aged <18 years with first radiologically confirmed AIS, from 2008 to 2015. Interhospital transfers of children with preexisting AIS diagnosis were excluded. Results— Twenty-three children were identified; 4 with unavailable ambulance records were excluded. Nineteen children were included in the study. Median age was 8 years (interquartile range, 3–14); median Pediatric National Institutes of Stroke Severity Scale score was 8 (interquartile range, 3–16). Emergency medical services call-taker diagnosis was stroke in 4 children (21%). Priority code 1 (lights and sirens) ambulances were dispatched for 13 children (68%). Paramedic diagnosis was stroke in 5 children (26%), hospital prenotification occurred in 8 children (42%), and 13 children (68%) were transported to primary stroke centers. Median prehospital timelines were onset to emergency medical services contact 13 minutes, call to scene 12 minutes, time at scene 14 minutes, transport time 43 minutes, and total prehospital time 71 minutes (interquartile range, 60–85). Conclusions— Emergency medical services call-taker and paramedic diagnostic sensitivity and prenotification rates are low in childhood AIS.