New Stroke Guidelines Highlight Expanding Role of Pediatric Stroke Care

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In early January, the American Heart Association and American Stroke Association published updates to their acute ischemic stroke guidelines, outlining the most up-to-date practices in stroke care, including recognition of unique considerations involved in pediatric stroke care. These recommendations, created after years of research efforts, primarily serve to standardize and optimize time-sensitive clinical care across diverse settings, ensuring that patients receive evidence-based interventions as quickly and safely as possible.

To discuss the clinical implications of these recommendations, NeurologyLive^® facilitated a conversation with Beth Anne Cavanaugh, MD, a pediatric stroke neurologist and director of the Pediatric Stroke Program at Le Bonheur Children's Hospital, and Andrei Alexandrov, MD, professor and chair of the Department of Neurology at the University of Arizona College of Medicine–Phoenix. Throughout the discussion, the clinicians covered several topics, including the pediatric considerations and the need for collaboration among pediatric specialists and adult stroke programs.

In this initial episode, Cavanaugh and Alexandrov highlight the importance of improving stroke recognition in children and ensuring access to specialized expertise, noting that relatively few pediatric stroke neurologists practice nationwide. The conversation also touches on practical considerations for implementing the guidelines, including appropriate imaging strategies to distinguish stroke from common pediatric stroke mimics and the potential role of advanced interventions in carefully selected patients. Overall, the discussion emphasizes how multidisciplinary collaboration and increased awareness may help improve outcomes for children experiencing stroke.

This transcript is edited for clarity. Click here to view more of our stroke coverage.

Cavanaugh, MD: I think the inclusion of pediatric recommendations in the guidelines has helped solidify the continued collaboration between children’s hospitals and adult stroke centers. I think we both have so much to learn from each other. I know it probably varies regionally, but the majority of children who present to Lebanon Children’s Hospital with arterial ischemic stroke actually come from outside hospitals. Usually, these are local emergency rooms with varying levels of stroke certification or experience with adult stroke. Improving education and raising awareness can only help improve outcomes and the collaboration between adult and pediatric specialists is key.

Alexandrov, MD: Dr. Cavanaugh, you invited me into this conversation by mentioning adult stroke centers. In talking about Dr Cavanaugh, I call her a “unicorn” of neurology because  she is a pediatric neurologist who also completed an adult stroke fellowship. That’s the kind of expertise children’s hospitals need nationwide. There are not more than 25 specialists like this in the entire country, Dr. Cavanaugh. It’s just a drop in the bucket; I may be off by five.

Cavanaugh, MD: I think this becoming more popular fellowship option because of all the advances that have been made in adult stroke care are really appealing to children, especially the interventions that don’t rely strictly on timelines. Since children often experience delays in diagnosis, so the 4.5-hour window for thrombolysis can sometimes be difficult to meet. But as we learn more about extended-window thrombectomy, it becomes a real option for some children.

Alexandrov, MD: Providers are sufficiently less than the number of children’s hospitals so there is a need to collaborate. The inclusion of pediatric stroke in the guidelines for the first time provides solutions and guidance and hospitals should seek advice. This encourages hospitals to develop systems for outreach, for example, Memphis Children’s Hospital has tele-outreach to regional facilities, allowing Dr. Cavanaugh to advise others remotely on pediatric stroke cases. Conversely, hospitals lacking pediatric stroke neurologists can reach out to adult stroke specialists and see what they think about that particular case.

Cavanaugh, MD: I think the guidelines really address all levels of stroke care, including prehospital assessment, emergency room evaluation, imaging approaches, thrombolysis, and endovascular thrombectomy. It’s wonderful that we’re having these discussions to identify pediatric patients who may benefit from hyperacute interventions.

As an overview, one thing that stood out to me in prehospital assessment is remembering that children are not little adults. Some adult screening tools used with adults don’t apply to children and have poor predictive value, but like any patient with acute neurological deficits, children should be evaluated for stroke. Stroke should be part of the differential diagnosis when a child presents with focal neurological deficits.

Regarding imaging, the guidelines highlight MRI and MRA, including cervical and intravascular vessels, as a reasonable approach, since children have higher rates of stroke mimics than adults. Not only is MRI beneficial because it avoids radiation and helps distinguish true strokes from mimics. Some common stroke mimics include traumatic brain injury, encephalitis, meningitis, or medication complications. When MRI or MRA is not readily available or is contraindicated, CT or CCTA using pediatric-specific metrics can also be reasonable for screening large vessel occlusions.