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Stroke Diagnosis in the Pediatric Emergency Department: An Ongoing Challenge.

See related article, p 1198. 

Diagnosis of pediatric stroke is often delayed, which has ramifications for the eligibility of children for hyperacute treatments such as thrombolysis and endovascular recanalization. Delayed pediatric stroke diagnosis occurs across developed countries, and delays occur at multiple stages of the prehospital, emergency room, and hospital course. In a Canadian cohort, median interval from symptom onset to diagnosis of arterial ischemic stroke (AIS) was 22.7 hours.1 Median delay in diagnosis was 29 hours in those with out-of-hospital strokes and 11.6 hours in those with in-hospital strokes. Interestingly, among those with out-of-hospital strokes, median time from symptom onset to hospital arrival was 1.7 hours, which indicates that most of the delay in diagnosis is on the part of medical staff. In fact, the median time from symptom onset to neuroimaging was 8.5 hours in the out-of-hospital group and 10.5 hours in the hospitalized group even though initial assessment was performed almost immediately in the hospitalized children. Lower Pediatric National Institutes of Health (NIH) Stroke Scale score, lack of seizure, and nonabrupt symptom onset were among predictors of prehospital delays. Lower Pediatric NIH Stroke Scale score also predicted delayed diagnosis in the hospitalized children. Merely 10% were diagnosed within 3 hours and 20% within 6 hours, precluding most from consideration for hyperacute therapies. In a population-based cohort from the United Kingdom, median time from symptom onset to diagnostic neuroimaging among children with AIS was 24.3 hours.2 A risk factor for delayed diagnosis for ischemic stroke was a normal head computed tomography scan, in which case median time to diagnosis was 44 hours. The Canadian study included children presenting from the early 1990s to the mid 2000s, …