Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke

Abstract

Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.

Endovascular clot retrieval for acute ischaemic stroke due to basilar artery occlusion in childhood

“…7,9,14 There are no randomized controlled trials evaluating ECR for BAO in adults, but multiple series and meta-analysis report considerable benefit in this group, including those treated more than 6 hours after symptom onset. [9][10][11] The low incidence of stroke, high frequency of stroke mimics, 15,16 and long delays to diagnosis 16 have combined to make timely therapeutic intervention problematic in children, and there are no randomized controlled trials of any therapy for paediatric stroke. However, the benefit of ECR in adult AIS, including patients with delayed diagnosis, has prompted consideration of ECR for selected paediatric strokes.…”

“…The low incidence of stroke, high frequency of stroke mimics, and long delays to diagnosis have combined to make timely therapeutic intervention problematic in children, and there are no randomized controlled trials of any therapy for paediatric stroke. However, the benefit of ECR in adult AIS, including patients with delayed diagnosis, has prompted consideration of ECR for selected paediatric strokes.…”

Childhood Arterial Ischaemic Stroke: Clinical Presentation, Risk Factors and Management

“…The extended diagnostic workup depends amongst others on medical history, results of neuroimaging, CASCADE classification and any further etiological hints. 47,48…”

“…If thrombolysis and thrombectomy are no treatment options, initial antithrombotic therapy is started with unfractionated heparin, low-molecular-weight heparin or acetylsalicylic acid (ASA), which may be switched after etiological classification. 47,48,61,62 In children with cardioembolic stroke or a stroke caused by a cervical arterial dissection, low-molecular-weight heparin or Vitamin K antagonists are recommended, whereas children with other underlying etiologies should be treated with ASA. 63 So far, direct oral anticoagulants are not licensed for the use in children.…”

Thrombolysis in a Child with Acute Arterial Ischemic Stroke without Large Vessel Occlusion

“…4,5 The Australian Clinical Consensus guideline for diagnosis and acute management of pediatric stroke states that thrombolysis "may be appropriate in specific children," and recommends consensusbased eligibility criteria [i.e., those from the "Thrombolysis in Pediatric Stroke Study" (TIPS) trial] and dosing (i.e., based on adult dosing guidelines). 6 The TIPS trial was a multisite, randomized controlled, dose-escalation trial intended to determine safety, dosing, and feasibility of IV tPA in pediatric AIS. 7 Initially funded by the NIH/NINDS in 2010, the TIPS trial closed by December 2013 due to the lack of recruitment.…”