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Code Stroke – a Diagnostic Approach

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This blog post was written as part of the QMUL DFTB PEM MSc.

You are called to resus at 11 pm to assess Ben. He is an 11-year-old boy who has been brought in by ambulance with acute onset slurred speech and right-sided weakness. His symptoms started an hour earlier at 10 pm. His mum reports that Ben’s sister has a seizure disorder and migraines, but Ben is fit and well with no previous medical problems.

Paediatric stroke

Although we think of stroke in children as rare, it is more common than a brain tumour and is among the top ten causes of death in childhood. An ischaemic stroke is a sudden focal infarction of brain tissue that is diagnosed with neuroimaging.  Paediatric stroke can be classified by type, the vessels involved and age of onset. Arterial ischaemic stroke (AIS) is the most common subtype, but others include cerebral sinovenous thrombosis (CSVT) and haemorrhagic stroke. Arteriopathies account for around 50% of cases with cardiac diseases being responsible for a further 25%. Less common causes include thrombophilic disorders and infections. AIS affects 1.2-8 per 100,000 children per year. 70% of survivors do so with a significant disability.

Delay in diagnosis is a global problem as we often think of mimics such as migraine, encephalitis, or seizure-related Todd’s paresis. Urgent neuroimaging is needed to diagnose stroke with treatment initiated within a 4.5-hour window.

You assess Ben using an ABCDE approach. He has a patent airway, with no respiratory or cardiovascular compromise and normal vital signs. You calculate his GCS as 13 (eyes opening spontaneously = 4, confused and slurred speech = 4, moves to localised pain but with right hemiplegia = 5). The nurse suggests you call an urgent code stroke. The neurology team, anaesthetist and PICU team arrive quickly. After assessment by the neurology team, and a brief discussion around the need for intubation Ben is taken for imaging, unintubated.

History and Examination

A focused history should ask about:

  • Recent head or neck injury
  • Varicella infection in the last 6-12 months
  • Previous migraine
  • Oral contraceptive pill use
  • Family history of early onset (<55 years) stoke, cardiac event or venous thrombosis
  • Recent head and neck infections
  • Congenital cardiac disease

The clinical examination should include:

  • Cardiac exam listening for murmurs, carotid or cranial bruits 
  • The presence of new onset seizures in newborns
  • The neurological system looking for focal signs as well as signs of raised intracranial pressure

Stroke scales and measures

Prompt diagnosis of childhood stroke enables reperfusion therapies, may prevent reoccurrence and minimise long term neurological damage. Unlike in the adult literature, the diagnostic accuracy of childhood stroke assessment tools is unclear. The most reliable stroke severity scale is the paediatric NIH stroke scale (PedNIHSS). This is a child specific adaption of the adult National Institutes of Health Stroke Score and can be used to quantify AIS severity and recovery. The PedNIHSS should be performed by a neurologist or trained assessor.

Take a look at the following links to help when examining patients, documenting findings, and thinking ab out treatment.

Thrombolysis in paediatric stroke proforma

Pediatric NIHSS from MD Calc

Ben’s PedNIHSS is 20. (range: 0 (minimal severity) – 41 (maximum severity). It is becoming clear that he may have had a stroke despite your initial reservations that they are very rare in children.

Investigations

Time is critical; potential therapies must be given early. Neuroimaging must be performed as soon as a potential stroke is identified.

A plain CT scan detects less than 50% of strokes. The gold standard in imaging is an MRI/angiography of the head and neck. If this is logistically challenging or cannot be done within 3 hours of symptom onset, then CT and CT angiography should be performed. If you suspect dissection you should include contrast angiography with head and neck imaging.

Bloods should be taken whilst gaining IV access and include venous gas, FBE, UEC, glucose, coagulation studies and group and save.

An ECG should be taken as soon as possible and an echocardiogram should be performed within 24 hours of admission.

Ben’s bloods are unremarkable. His ECG shows a sinus arrhythmia. His MRI shows areas of restricted perfusion within the territory of the middle cerebral artery (MCA) and complete occlusion of the proximal left MCA. He is transferred to an adult hospital close by for clot retrieval.

Follow this link to view the RCPCH clinical guideline on paediatric stroke.

References

deVeber GA, Kirton A, Booth FA, Yager JY, Wirrell EC, Wood E, et al. Epidemiology and Outcomes of Arterial Ischemic Stroke in Children: The Canadian Pediatric Ischemic Stroke Registry. Pediatr Neurol. 2017;69:58-70.

Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ. Antithrombotic and thrombolytic therapy: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2008;133(6):110S-2S.

Ichord RN, Bastian R, Abraham L, Askalan R, Benedict S, Bernard TJ, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke. 2011;42(3):613-7.

Ladner TR, Mahdi J, Gindville MC, Gordon A, Harris ZL, Crossman K, et al. Pediatric Acute Stroke Protocol Activation in a Children’s Hospital Emergency Department. Stroke. 2015;46(8):2328-31.

Lehman LL, Khoury JC, Taylor JM, Yeramaneni S, Sucharew H, Alwell K, et al. Pediatric Stroke Rates Over 17 Years: Report From a Population-Based Study. J Child Neurol. 2018;33(7):463-7.

Long E, Saw JTS, Davis C, Morgan C, Sheridan B, Monagle P, et al. Paediatric Code Stroke. J Paediatr Child Health. 2022;58(2):356-9.

Mallick AA, Ganesan V, Kirkham FJ, Fallon P, Hedderly T, McShane T, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg Psychiatry. 2015;86(8):917-21.

Suppiej A, Gentilomo C, Saracco P, Sartori S, Agostini M, Bagna R, et al. Paediatric arterial ischaemic stroke and cerebral sinovenous thrombosis. Thrombosis and haemostasis. 2015;113(06):1270-7.

The Diagnosis and Acute Management of childhood stroke. Clinical Guideline 2017. Available at https://www.mcri.edu.au/sites/default/files/media/stroke_guidelines.pdf (accessed 10/04/2022)

About the authors

  • Tom is a Paediatric Registrar in Melbourne, Australia and research fellow at Murdoch Children’s Research Institute (MCRI) with Interests in sepsis and fluid management. When not at work he can be found at the beach with his biggest life companion Rupert the Labrador. He/Him.

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