The director of the Pediatric Stroke Program at CHOP spoke about the need to improve early recognition of pediatric stroke and physician awareness of the condition, which many believe is underdiagnosed and underestimated.
Rebecca Ichord, MD
Despite the advent of a number of interventions for stroke in adult patients, such as thrombectomy and thrombolysis, a lack of randomized and controlled trials in pediatric patients with acute arterial ischemic stroke has limited the ability of physicians to develop guidelines for the treatment of these younger patients, and when patients present, very rarely does the provider jump to the conclusion of childhood stroke.
And while childhood stroke is not entirely common, it is likely more common than realized, as many believe it is often undiagnosed or misdiagnosed. Rebecca Ichord, MD, director, Pediatric Stroke Program, Children’s Hospital of Philadelphia (CHOP), told NeurologyLive®
that improvements in early recognition and assessments still need to be improved. As of now, raising awareness for pediatric stroke would be a step toward achieving that goal.
Ichord also discussed the obstacles caused by the differences between treating this in pediatric patients compared to adults—even at an equipped pediatric hospital such as CHOP—and how they can be addressed in care.
NeurologyLive®: What is the biggest challenge in the treatment of pediatric stroke?
Rebecca Ichord, MD:
The biggest challenge is early recognition and then early access to high-level assessments. The ability of community hospitals to No. 1, think about stroke in a child is still at a level that needs improvement. It's certainly much better now than it was, say, 10–15 years ago, but the last thing on anyone's mind usually when a child presents with an acute focal seizure followed by an acute hemiparesis is stroke. They usually think of 5 or 6 other things that are much more common. The problems are for people, including parents as well as providers, to think of stroke. Then, once they think of stroke, they have to be able to overcome the additional barriers that children present, which is getting to a qualified facility. There are many people out in the wide world, and community hospitals are a long way from advanced imaging and advanced stroke care for a child.
Are there pediatric-specific obstacles in the approach to caring for a child with stroke?
The barriers for children to get imaging, for example, are different than for an adult. Children often need to be sedated, they have to have IV access that is adequate for getting, for example, a CT angiogram. Shepherding a child and their family through this kind of process of evaluation and getting access to the qualified neurology providers, the imaging, and then mobilizing the team that's necessary for a hyperacute intervention is daunting. Even in a place like ours, where we've been motivated and focused on treating children with stroke, it is still a big undertaking to mobilize anesthesia, advanced imaging, interventional radiologists. All of that involves a big commitment on the part of the institution, and the providers, and a very large team who can communicate with amongst each quickly and effectively and get a child in.
In addition to imaging limitations, are there intervention-related challenges in pediatric stroke? Are we addressing these currently?
One of the other major limiting factors—that will probably not be able to overcome in the near future—is just size and age. The current thrombectomy technology was developed for adults, and so, you can imagine for a child who's aged under 3 years—that technology is simply not usable or has very limited use in a child under the age of 3 because their vessels are very small.
Our ability to finally narrow down the timeframe of when they were last seen and their symptom onset is much more challenging in a pre-verbal or very young child. Defining those windows of therapy and when it's safe and when it should be considered is just simply much more difficult in the very young child. As it turns out, in our group of children who had a deficit that might qualify, almost half of them were under the age of 3. This is a young child's problem and it's just challenging.
Another aspect of this is that the children that are at greatest risk are often those that are hospitalized, for example, with severe heart disease or other life-threatening conditions and they often are difficult to recognize when they are having a new symptom and they are sedated or intubated. Defining that group of very high-risk children, as to when they actually had symptoms of a stroke and dealing with their other critical illness and getting them shepherded through anesthesia and intervention is also really, really challenging. It's still a process that we as a community are working with improving.
Transcript edited for clarity
Hutchinson M, Kimmel A, Granath C, et al. Potential eligibility for hyperacute treatment in childhood acute arterial ischemic stroke: findings from a single-center 12-year cohort study. Presented at: 2019 American Academy of Neurology Annual Meeting. May 4-10, 2019; Philadelphia, PA.