Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke

• Published in: Stroke (1970) 2009, Vol.40 (1), p.58-64
• Main Authors: RAFAY, Mubeen F, PONTIGON, Ann-Marie, CHIANG, Jackie, ADAMS, Margaret, JARVIS, D. Anna, SILVER, Frank, MACGREGOR, Daune, DEVEBER, Gabrielle A
• Format: Article
• Language: English
• Subjects: Acute Disease; Adolescent; Biological and medical sciences; Brain Ischemia - diagnosis; Brain Ischemia - physiopathology; Caregivers - statistics & numerical data; Caregivers - trends; Child; Child, Preschool; Cohort Studies; Diagnostic Errors - prevention & control; Diagnostic Imaging - statistics & numerical data; Diagnostic Imaging - trends; Early Diagnosis; Emergency Medical Services - standards; Emergency Medical Services - statistics & numerical data; Emergency Medical Services - trends; Female; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Hospitalization - statistics & numerical data; Hospitalization - trends; Humans; Infant; Infant, Newborn; Male; Medical sciences; Nervous system (semeiology, syndromes); Neurology; Neurology - standards; Neurology - statistics & numerical data; Outcome Assessment (Health Care); Pediatrics - standards; Pediatrics - statistics & numerical data; Quality of Health Care - standards; Quality of Health Care - statistics & numerical data; Quality of Health Care - trends; Retrospective Studies; Stroke - diagnosis; Stroke - physiopathology; Time Factors; Vascular diseases and vascular malformations of the nervous system
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/strokeaha.108.519066

For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and neuroprotective strategies. We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis. A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent's help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis. In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.