Consult neurosurgery, off pathway
Consult pediatric neurology, institute neuroprotective measures
Patient requires immediate resuscitation?
Patient tolerated MRI?
Meets criteria for IV thrombolysis?
Begin resuscitation and consider treatment for acute herniation if necessary
Concern for hemorrhagic stroke?
Head of bed flat
Severe hypertension?
Evaluate for other acute interventions relevant to the particular presentation: infection (CSF studies, antibiotics), seizures (EEG, anti-epileptic medications), cardiac ischemia (troponin), etc.
MRI immediately available?
Requires anxiolysis for imaging?
Patient expected to tolerate MRI?
DISCUSS with neurology prior to starting antihypertensives; if approved, nicardipine and labetalol preferred (short-acting, easily titratable agents)
Worrisome signs for hemorrhagic stroke
Meets criteria for thrombectomy?
Procedural sedation with ketamine by the pediatric ED attending (UNLESS the attending is actively resuscitating a severely ill child and cannot be covered)
Risk factors in children and adolecents
Cardiac
Hematologic
Vascular
Metabolic
Ingestion
Hypertension in ischemic stroke
PICU admission, transthoracic echocardiography
Stat head CT +/- CTA (per ped neurology) followed by admission for MRI under general anesthesia (goal to MRI < 48 hours)
Criteria for thrombectomy
IR thrombectomy
Clinical findings concerning for acute stroke
IV tPA exclusion criteria (peds)
IMAGING:
EXAM:
LAB:
Goal: First neuroimaging within < 60 min
Treat appropriately, off pathway
Criteria for IV thrombolysis
Head of bed elevated (30 degrees)