Pediatric Case - Ep.1/2 - SLICE Worldwide 2022 - Cesare DOMINGO

What do you need to do to set up Childhood stroke Protocols and Pathways?

Although guidelines for acute stroke management in children exist, pediatric stroke treatment remains heterogeneous. In the past years children with acute ischemic stroke were increasingly treated with reperfusion therapies, intravenous tissue plasminogen activator (IV-tPA), and mechanical thrombectomy.

However, treatment with reperfusion therapies requires timely identification of stroke, which is a significant challenge for hospitals and practitioners. Setting up dedicated Childhood Stroke Protocols and Pathways has been shown to improve number of children receiving reperfusion treatments and to decrease in-hospital delays, here are some minimal recommendations that Childhood Stroke Pathways should contain:

Minimal recommendations for Childhood Protocols:

1. Ensure that your pediatrics department has at least one pediatric neurologist with expertise in childhood stroke on staff;
2. Establish hyperacute stroke management recommendations and ensure they are known by all pediatric neurologists who are on call; 
3. Create an acute stroke pathway in your hospital/ system of care. Acute stroke alerts should be activated by a diversity of providers, and the alert should be received by child neurologists, child intensive care personnel, radiologist, neuroradiologist, neurosurgeons, and your stroke interventional team; 
4. Ensure that once a stroke alert is called, a resident or senior with expertise in pediatric neurology is to be the first responder;
5. Ensure that even if the first responder is not in-house, he has the necessary support to call other practitioners involved in the case;
6. Ideally, access should be given to the pediatric stroke alert system in all hospitals that receive pediatric patients in the region; They should be notified, and a regional pediatric stroke plan should be developed; 
7. First neuroimaging when the stroke is suspected in a child should be magnetic resonance imaging (MRI); This involves good collaboration with the anesthesia team as it frequently implies general anesthesia (GA) as well. Protocols usually include diffusion weighted imaging (DWI), susceptibility weighted imaging (SWI), Fluid attenuation inversion recovery (FLAIR), time-of-flight (TOF), and Perfusion (mainly after 6 hours). Ideally, MRI should be available 24/7;
8. If MRI is not available, in the face of stroke suspicion, a native computed tomography (CT) should be automatically completed with at least CTA, if not also CTP (if more than 6 hours);
9. Aim for suspicion to imaging times of less than 60 min as goals;
10. IV-tPA should be available, and personnel should be trained to administer it; 
11. If neuro-interventional radiology is not available on-site. Transfer protocols should be set up and coordinated with neuro-interventional departments.
12. If patients get transferred to an adult hospital, transfer protocols should involve collaboration between the anesthesia teams of the pediatric and adult hospital to ensure adequate anesthesia management during the thrombectomy procedure;
13. If patients get transferred to an adult hospital, transfer protocols should ensure that a dedicated pediatric neurologist is available or easily joinable before, during, and immediately after the procedure to discuss important details with the interventionalist;
14. After the thrombectomy procedure, children should be transferred in a pediatric ICU; 
15. Adult stroke neurologists may be essential members of the pediatric stroke team as their experience with acute cerebrovascular disease can sometimes be of help; 
16.  Transfer protocols, role of pediatricians/ pediatric neurologist/ adult neurologists and intensivist should be made clearly and everybody should be notified as to reduce the loss of time due to confusion in the acute setting;  

Conclusion:

Childhood stroke protocols and pathways are desperately needed to improve access to reperfusion therapies. They were shown to reduce the time to imaging and time to treatment and ensure optimization throughout the difficult pre-treatment phase of a childhood stroke, where errors are usually committed that lead to important delays in diagnosis. Clear directions and inter-hospitals protocols should be in place to reduce confusion in the acute setting once practitioners are faced with a rare situation.

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