Consult neurosurgery, off pathway
Consult pediatric neurology, institute neuroprotective measures
Patient requires immediate resuscitation?
Patient tolerated MRI?
Meets criteria for IV thrombolysis?
- Clinical signs of stroke: Weakness or sensory change on one side of the body, vision loss, speech difficulty, dizziness/imbalance/problem with coordination
- Sudden/Acute onset < 6 hours prior
- Unknown last seen normal, or symptom onset > 6 hours prior to presentation
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?
- Page 'Ped Stroke Code'
- Ped neurology resident/fellow responds immediately (at bedside in < 30 minutes)
- Start neuroprotective measures
- Cardiorespiratory monitoring
- NPO
- Normovolemia: Isotonic fluids only, 0.9%NS at maintenance
- Normoglycemia: avoid dextrose-containing fluids unless hypoglycemic
- Normothermia: acetaminophen or cooling blanket for temp > 37.5 (except in sickle cell patients)
- Neurologic checks Q1 hour minimum
DISCUSS with neurology prior to starting antihypertensives; if approved, nicardipine and labetalol preferred (short-acting, easily titratable agents)
Worrisome signs for hemorrhagic stroke
- Signs of increased intracranial pressure
- Headache/nausea/vomiting
- Decreased level of consciousness / altered mental status
- Bilateral blurred vision / papilledema
- CN VI palsy (usually bilateral)
- Bulging fontanelle
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
- Congenital heart disease or patent foramen ovale
- Atrial fibrillation and other arrhythmias
- Cardiomyopathy, myocarditis or endocarditis
- Cardiac surgery, catheterization or prosthetic valve
- Extracorporeal membrane oxygenation (ECMO)
- Rheumatic heart disease or myocardial infarction
Hematologic
- Sickle cell disease and iron deficiency anemias
- Inherited prothrombotic states
- Acquired prothrombotic states
Vascular
- Non-inflamatory: Arterial dissection, Moyamoya, transient cerebral arteriopathy, connective tissue disease (Ehlers-Danlos, Marfan), Radiation-induced vasculopathy, reverse cerebral vasoconstrictive syndrome, migrainous stroke
- Inflamatory: Arteritis, Kawasaki disease, Polyarteritis nodosa, Vasculitis, Angiitis
Metabolic
Ingestion
- Cocaine, methamphetamine
- 54% of children were previously healthy with no known risk factors for stroke prior to their event
Hypertension in ischemic stroke
- Systolic BP target is at the 50-95th percentile for age
- In adults, permissive hypertension allowed in the acute stroke period
- Blood pressure goals post-stroke have not been well-studied in children, but can consider allowing blood pressure to rise to 15-20% above 95th percentile for age
- Monitor exam closely with pediatric neurology; if no exam fluctuations at a lower pressure or sustained hypertension >20% over the 95th percentile for age favor labetalol or nicardipine (short acting, titratable agents)
- Avoid nitroprusside which can cause cerebral vasodilation
- Table of BP by age from NIH
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
- Age > 2 years
- Proximal vessel cutoff visualized on neuroimaging and accessible by endovascular means
- Symptom onset to groin puncture time < 6 hours
IR thrombectomy
Clinical findings concerning for acute stroke
- Focal weakness
- Hemiparesis
- Aphasia
- Visual disturbance
- Cerebellar signs
- Seizures
- Altered mental status
- Neck pain (cervical artery dissection)
- Horners syndrome (carotid dissection)
IV tPA exclusion criteria (peds)
- >4.5 hours from last seen normal
- < 2 years old
- unknown time of onset
- Minor/nondisabling deficits
- Stroke, major head trauma or intracranial surgery in the past 3 months
- Major surgery, biopsy, or arterial puncture at a non-compressible site in the past 2 weeks (relative contraindication)
- GI or GU bleeding within 21 days (relative contraindication)
- History of brain tumor, AVM, aneurysm or prior intracranial hemorrhage
- Patient with malignancy or within one month of completing cancer treatment
- Underlying significant bleeding disorder
- Previously diagnosed primary angiitis CNS or secondary arteritis
- Clinical presentation c/w acute MI or post-MI pericarditis
- Patient would decline blood transfusion
- Stroke due to bacterial endocarditis, sickle cell disease, meningitis, bone marrow, air or fat embolism, moyamoya disease
IMAGING:
- Imaging suggestive of malignant stroke (hypodensity on CT/ASPECTS <=7 or DWI lesion > 1/3 MCA territory)
- Intracranial cervicocephalic arterial dissection
- Symptoms suggestive of SAH even with normal CT/MRI
EXAM:
- Systolic BP >15% above the 95%ile for age (treat with labetalol or nicardipine)
LAB:
- Glucose < 50 or > 400, platelets < 100,000, INR > 1.4
Goal: First neuroimaging within < 60 min
Treat appropriately, off pathway
Criteria for IV thrombolysis
- Age > 2 years
- DWI lesion within a vascular territory consistent with stroke on MRI
- Vessel cutoff visualized on neuroimaging
- Patient confirmed last seen normal < 4.5 hours
- No exclusion criteria met (see separate box)
Head of bed elevated (30 degrees)
