www.jpeds.

com + THE JOURNAL OF PEDIATRICS

ORIGINAL
®
ARTICLES
Pediatric Acute Stroke Protocols in the United States and Canada
Dana B. Harrar, MD, PhD', Giulia M. Benedetti, MD’, Anuj Jayakar, MD°, Jessica L. Carpenter, MD', Tara K. Mangum, DO,
Melissa Chung, MD°, and Brian Appavu, MD‘, on behalf of the
International Pediatric Stroke Study Group and Pediatric Neurocritical Care Research Group*

Objective To describe existing pediatric acute stroke protocols to better understand how pediatric centers might
implement such pathways within the context of institution-specific structures.
Study design We administered an Internet-based survey of pediatric stroke specialists. The survey included
questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke
response, imaging, and hyperacute treatment.
Results Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children’s hos-
pital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke.
Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing,
the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page.
Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbrevi-
ated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-
based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator
(IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey.
Conclusions An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute
stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience
providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric
acute stroke diagnosis and hyperacute management. (J Pediatr 2022;242:220-7).

As: ischemic stroke is a leading cause of morbidity and mortality in children” and is associated with high costs of
care’ and decreased quality of life among survivors.’ The widespread use of hyperacute therapies, such as intravenous
tissue plasminogen activator (IV-tPA) and mechanical thrombectomy, has led to the development of high-level, evi-
dence-based guidelines for the treatment of adult arterial ischemic stroke.” The certification of adult stroke centers also has
resulted in the standardization of acute stroke care, with downstream benefits including increased use of I[V-tPA and improve-
ments in acute hospital care and long-term outcomes.’ Although evidence-based guidelines for acute stroke management in
children exist,”'' pediatric stroke care remains quite variable.'~'*
Children with arterial ischemic stroke are increasingly treated with IV-tPA and mechanical thrombectomy.'”~’ Treatment
with hyperacute therapies requires the timely identification of stroke, which historically has proven challenging in children.°***
Delays in diagnosis prompted pediatric centers in North America to develop multidisciplinary stroke teams capable of an emer-
gent around-the-clock response to children with acute-onset focal neurologic deficits as part of the Thrombolysis in Pediatric
Stroke (TIPS) trial.**° A few centers have gone on to describe the implementation of their acute stroke response protocols'* '°
with intervals from emergency department (ED) arrival to neuroimaging ranging
from 1 to 4 hours.'”'° However, there remains significant heterogeneity among
pediatric institutions in the implementation of acute stroke response protocols," From the ‘Department of Neurology, Children's National,
with substantial variation in local staffing and resource availability. In this study, Hospital and Departments of Neurology and Pediatrics,
" een x George Washington University School of Medicine,
we examined pediatric acute stroke response protocols in the US and Canada in Washington, DC; ?Department of Neurology, Seattle
‘attri centers might
an effort to better understand how pediatric icht j
implement such pro: _ Children’s
Seale, WA:Hospital and University
“Department of Washington,
of Neurology, Nika
tocols within the context of institution-specific structures. Children’s Hospital,
Neurology, Miami, FL; Hospital,
Phoenix Children’s “Department of AZ;
Phoenix,
and “Divisions of Critical Care Medicine and Pediatric
Neurology, Department of Pediatries, Nationwide
Children’s Hospital, Columbus, OH
Computed tomography “A list of additional study group members is available at
Diffusion-weighted imaging www. jpeds.com (Appendix).
Emergency department ‘The authors dectare no conflicts of interest.
Portions ofthis study were presented atthe Intemational
Intravenous Pediatric Stroke Organization Congress, July 19-21,
Magnetic resonance 2021, Virtual and the Annual Meeting of the Child
Magnetic resonance imaging Neurology Society, September 29-October2, 2021
Thrombolysis in Pediatric Stroke
Tissue plasminogen activator 0022-3476/8-see ront matter. ©2021 Elsevier Inc. Allrights reserved.
hitps:/doiorg/10.1016,peds.2021.10.048
220

Study Design
This study was approved by the Institutional Review Board of
Phoenix Children’s Hospital (S-IRB-20-192) and was certi-
fied exempt by the Institutional Review Board of Children’s
National Hospital (Pro00014012). We developed and tested
a conditional branching survey comprising 6 sections: (1)
hospital demographics, (2) child neurology and pediatric
stroke demographics, (3) acute stroke response, (4) imaging,
(5) hyperacute treatment, and 6) miscellaneous logistics
(Figure 1; available at www.jpeds.com). The survey
consisted of 6 pages of 4-11 questions each. It was possible
to skip questions and to review and change answers before
submission. No consistency or completeness check was
required before submission. The survey was distributed
using REDCap software.*°
Survey Recipients
An advertisement addressed to pediatric stroke specialists
and containing a link to the survey was sent through the In-
ternational Pediatric Stroke Study and Pediatric Neurocriti-
cal Care Research Group listservs. We requested that only 1
survey be completed per institution, and provided no incen-
tives for completing the survey. Clicking the link to the sur-
vey was considered consent to participate, and responses
were anonymous. We did not use cookies, IP checks, log
file analyses, or registration to prevent duplicate responses,
nor did we use timestamps to determine the time required
to complete the survey. A reminder was sent through the list-
servs approximately 2 weeks after the posting of the original
advertisement. The survey was closed 2 weeks after the last
survey response was received.
Survey Analyses
Surveys devoid of responses, as well as those describing insti-
tutions outside the US and Canada, were excluded from our
analysis. Not all respondents answered all questions in the
survey (11 surveys were incomplete), and thus the analysis
was performed accounting for the number of responses for
each individual question. For some questions, more than 1
response was permitted. Descriptive statistics were per-
formed using count (n) and percentage (%) for categorical
variables. Neither randomization of questions nor statistical
correction was performed.
Of 70 surveys opened, 11 were devoid of responses, and 12
described institutions outside the US and Canada; all these
were excluded from further analysis. A total of 47 surveys
were analyzed, including 44 from the US and 3 from Canada.
There are approximately 250 children’s hospitals in the
US, including tertiary and nontertiary centers’; thus,
approximately 20% of US pediatric institutions were repre-
sented in the analysis.
Volume 242 « March 2022
Institutional and Stroke Program Demographics
Table I (available at www.jpeds.com) shows the
demographics of the institutions and stroke programs
represented in the survey. Most of the institutions are
freestanding children’s hospitals (n = 32 of 47; 68%) with
>50000 ED visits annually (n = 19 of 35; 58%) and >25
cardiac and pediatric intensive care unit beds (n = 38 of 46;
83%). Most have moderate-sized neurology departments
including 6-20 attendings (n = 26 of 42; 62%) and 1-4
(n = 34 of 44; 77%) child neurology residents. The
majority of the institutions have at least 1 neurologist with
expertise in pediatric stroke on staff (n = 32 of 42; 76%);
this is often a single individual (n = 15 of 42; 36%). Fewer
than one-half of the institutions have an inpatient pediatric
stroke consult service (n = 19 of 45; 42%). All inpatient
stroke consult services offer hyperacute stroke management
recommendations, and approximately two-thirds also offer
guidance on nonacute stroke management (n = 11 of 17;
65%). Most institutions have a stroke clinic (n = 31 of 42;
74%); however, few have a stroke training program (n = 9
of 42; 21%).
Stroke Alert Systems
Table II presents characteristics of the acute stroke response
pathway at the respondents’ institutions. Most institutions
have an acute stroke pathway (n = 41 of 42; 98%), and the
majority include the activation of a stroke alert page
(n = 38 of 41; 93%). The stroke alert page can be activated
by a diversity of providers, typically without requiring a
neurology consultation for activation. The stroke alert page
also is received by a range of providers, most commonly
child neurologists, radiologists, and intensivists. The
majority of institutions allow for a stroke alert to be
activated up to 24 hours after the onset of symptoms
(n = 22 of 39; 56%), with fewer institutions allowing for a
stroke alert to be called after this time (n = 12 of 39; 31%).
The first responder after hours to a stroke alert page is
most often a child neurology resident (n = 33 of 41; 80%),
adult neurology resident (n = 18 of 41; 44%), or child
neurology attending (n = 10 of 41; 24%). Relatively few first
responders are in-house after hours (n = 12 of 40; 30%), with
most first responders traveling to the hospital from home
(n = 29 of 40; 73%). Most stroke consults are staffed with
either a general child neurology attending (n = 22 of 36;
61%) or pediatric stroke attending (n = 17 of 36; 47%).
Neuroimaging
Table III lists characteristics of the acute stroke neuroimaging
protocols at the respondents’ institutions. Most institutions
prefer magnetic resonance imaging (MRI) (n = 24 of 37;
65%) for a child with suspected stroke, and most use
abbreviated MRI protocols, with all institutions obtaining
diffusion-weighted imaging (DWI) and more than
two-thirds also obtaining a susceptibility-weighted or
gradient recalled echo image (n = 21 of 24; 88%), a fluid-
attenuated inversion recovery image (n = 19 of 24; 79%),
and time of flight magnetic resonance (MR) angiography of
221
THE JOURNAL OF PEDIATRICS « www.jpeds.com Volume 242

Table Il. Characteristics of stroke alert systems Table I. Continued

Characteristics 1 (%) Characteristics

Centers with a stroke alert pathway (N = 42) 41 (98) NIHSS

Centers with a stroke alert pathway tailored to the 831) Faculty stroke scale certification (N = 37)
cardiac ICU (N = 26) Stroke scale use by non-neurologists (N = 38)
Centers with a stroke alert pathway tailored to 22 (67) ED attendings
sickle cell disease (N = 33) ICU attendings
Centers with stroke alert page (N = 41) 38 (93) ED fellows
Recipients of stroke alert page (N = 38)" ICU fellows
General child neurology resident/fellow 31 (82) ED nurses
MRI technologist 19 (60) Neurosurgery residents
General child neurology attending 18 (47) Other
Radiologist 17 (45)
ICU attending 16 (42) ‘NIHSS, National Institutes of Health Stroke Scale; ICU, intensive care unit.
ICU fellow 14.87) *More than 1 response permitted.
Pharmacy 12 (82)
Adult neurology resident 1129)
Anesthesiologist 10 (26)
CT technologist 10 (26) the head (n = 17 of 24; 71%). For institutions with a goal time
Pediatric stroke attending 10 (26) for obtaining neuroimaging, imaging is most often expected
Adult stroke fellow 9 (24) within 60 minutes (n = 11 of 23; 48%). MRI is accessible
Rapid response team or equivalent 9 (24)
Adult stroke attending 7 (18) overnight at most institutions (n = 35 of 37; 95%), with
Neurocritical care attending 7 (18) approximately one-half (n = 16 of 37; 46%) having an MRI
Neurointerventional radiologist 6 (16) technologist in-house 24/7 and the other one-half (n = 19 of
Neurosurgeon 5 (13) 37; 54%) having to call an MRI technologist in from home.
Hematologist 4(11)
Neurocritical care fellow 4(11) Sedated MRI is also available at most institutions overnight
Pediatric stroke fellow 3 (8) (n = 34 of 35; 97%) with some having an anesthesiologist
Other 5 (13) in-house overnight (n = 21 of 35; 60%) and the remainder
Time after symptom onset within which a
stroke alert can be called (N = 39) having to call an anesthesiologist in from home (n = 13 of
Up to 4.5 h 1) 35; 40%). Moreover, most institutions permit the
Up to 6h 1()
Up to 8h 1() interruption of an ongoing nonurgent MRI to facilitate an
Up to 24h 22 (56) emergent MRI in a patient who is a potential IV-tPA
Up to 48 h 3 (8) candidate (n = 25 of 35; 71%).
More than 48 h 9 (23)
Other 3(8) Given the potential for late-window mechanical throm-
Neurology first responderto stroke page (N = 41)" bectomy and the importance of perfusion imaging in the se-
General child neurology resident/fellow 33 (80) lection of adult patients for this intervention," we queried
‘Adult neurology resident 18 (44)
the availability of perfusion imaging; most institutions have
General child neurology attending 10 (24)
Neurocritical care attending 5 (12) either computed tomography (CT)-based (n = 25 of 37;
Neurocritical care fellow 4 (10) 68%) and/or MR-based (n = 28/35; 80%) perfusion imaging
Pediattic stroke attending 4 (10)
Pediattic stroke fellow 3(7) available; only 3 institutions have neither imaging modal-
Adult stroke fellow 26) ity available.
Adult stroke attending 0
Other 37)
Location of first responder (N= 40)" Hyperacute Therapies
Already in-house 12 (80) IV-tPA was administered to at least | patient at most institu-
Goes to hospital from home 29 (73) tions (n = 23 of 33; 70%) in the year before our survey
Manages from home via telephone 10 (25) (Figure 2). At many institutions, confirmation of an infarct
Manages from home via telemedicine 4 (10)
Other 38) is required before [V-tPA administration (n = 23 of 34;
Time within which home responders are expected 68%), whereas a vessel cutoff is required at fewer than one-
at bedside (N = 27) half (n = 15 of 34; 44%) (Table IV). At most centers, the
No specified time
<20 min decision to administer IV-tPA is made by a neurologist
<30 min (n = 32 of 34; 94%), alone or in collaboration with other
<45 min
<60 min providers, with IV-tPA most commonly administered by
Other the bedside nurse (n = 17 of 34; 50%). Post-tPA care is
Staffing of stroke alerts (N = 36)* provided in the pediatric critical care unit at all institutions
General neurology attending on call 22 (61)
Pediattic stroke attending 17 (47) (n = 34 of 34; 100%), with some also providing care for
Neurocritical care attending 8 (22) specific patients in an adult critical care unit (n = 4 of 34;
Adult stroke attending 7 (19) 12%) or cardiac intensive care unit (n = 1 of 34; 3%).
Other 4(11) At most institutions, at least 1 patient had undergone or
Stroke scale use (N = 39)*
Pediatric NIHSS 38 (97) been transferred for mechanical thrombectomy in the pre-
(continued) ceding year (n = 25 of 33; 76%) (Figure 2), with many
Harrar et al
March 2022 ORIGINAL ARTICLES

performing or transferring for mechanical thrombectomy

Table III. Acute stroke neuroimaging protocols >6 hours after symptom onset (n = 16 of 24; 64%) (Table
Protocols 1 (%) IV). Most commonly, institutions rely on the
Preferred initial imaging modality (N = 37) neurointerventional radiology team at an adult hospital for
MRI/MRA 18 (49) mechanical thrombectomy, with few having a dedicated
CTICTA 9 (24) pediatric neurointerventional radiologist available around-
MRI 6 (16)
cT 38) the-clock for mechanical thrombectomy (n = 9 of 36; 25%)
Other 1) (Table IV). Like post-tPA care, post-thrombectomy care is
MI protocol (N = 24)" typically provided in the pediatric critical care unit (n = 32
Dwi 24 (100)
SWVGRE 21 (88) of 33; 97%), with some institutions also providing care for
FLAIR 19 (79) specific patients in an adult critical care unit (n = 7 of
TOF-MRA head 1771) 33; 21%).
T2-weighted 15 (63)
T1-weighted 12 (60)
ASL 7 (29)
TOF-MRA neck 7 29)
Other 14)
Goal time for neuroimaging (N = 23)
<30 min 6 (26) The ability to rapidly diagnose and triage a child with a sus-
<45 min 3. (13) pected stroke has improved over the past decade.'?!®'”
<60 min 11 (48) Moreover, this ability is no longer limited to a few flagship
<90 min 0
<120 min 0 institutions; acute stroke response protocols have expanded
No specified time frame 3 (13) well beyond the centers that paved the way for stroke alert
Availability of MRI overnight (N = 37) 35 (95) systems in children as part of the TIPS trial.“**? Our survey
Availability of anesthesia overnight (N = 35) 34 97)
lity to interrupt a nonurgent MRI for a potential 25 (71) results describe acute stroke response practices as imple-
IV-tPA candidate (N = 36) mented by more than 40 institutions in the US and Canada.
Availability of perfusion imaging By taking into consideration local staffing structures and
CT (N= 37) 25 (68)
MR (N = 35) 28 (80) institutional resource availability, the patterns described
Emergent interpretation of CT perfusion (N = 24)* here can serve as a framework for how institutions might
Neuroradiology 16 (67) implement a pediatric acute stroke response protocol given
Adult stroke team 9 (38)
Radiology 5 (21) their own unique systems of care and resource
General child neurology team 417) considerations.
Neurocritical care team 4(17) Timely neuroimaging is a central component of pediatric
Pediatric stroke team 3(13)
Other 5 (21) acute stroke response protocols. It allows one to address
one of the major challenges in acute pediatric stroke care,
ASL, arterial spin labeling; CTA, computed tomography angiography; FLAIR, fluid-attenuated namely differentiating a child with a stroke from a child
inversion recovery; GRE, gradient recalled echo; MRA, magnetic resonance angiography;
‘SIM, susceptibility weighted imaging; TOF-MRA, time of fight magnetic resonance angiog- with a stroke mimic, which is not always possible based on
raphy.
*More than 1 response permitted. history and examination alone.“”'! In a child with a

A IV-tPA in year prior to survey B Thrombectomy in year prior to survey

16 as 16
14 14
Rw 12 Bry
£ 10 a
210 10
g 2 8 8
a8 a8
3 6 356
56
2 2 3
2
2 r 2 | _ I
° ms ° =
° 1 2 3 4 Se o a 2 3 4 5+
Numberof patients Numberof patients

Figure 2. Hyperacute therapy in children. A, Administration of IV-tPA in children during the year before distribution of the survey.
B, Performance or transfer for mechanical thrombectomy in children during the year before distribution of the survey.

Pediatric Acute Stroke Protocols in the United States and Canada 223
THE JOURNAL OF PEDIATRICS « www.jpeds.com Volume 242

stroke found that a limited-sequence MRI, including DWI, is

Table IV. Logistics of hyperacute therapy as sensitive for the detection of stroke as a full-sequence
Procedures n(%) MRI."** This suggests that it might be possible to strike a
VPA balance between reaping the benefits of MR-based imaging
Confirmation of infarct required for IV-tPA 23 (68) while minimizing the time spent in the MRI scanner. For
administration (N = 34) children who present >6 hours after symptom onset, perfu-
Vessel cutoff required for administration 15 (44)
of IV-tPA (N = 34) sion imaging may be important in determining candidacy
Placement of IV-tPA order (N = 36)” for mechanical thrombectomy. Although the precise role of
ED resident 12 (83) perfusion imaging in children remains to be determined,"”
General child neurology attending 12 83)
ICU attending 12 (83) most centers are capable of performing perfusion imaging
ED attending 10 (28) in children.
General child neurology resident/fellow 10 (28) In keeping with the importance of MR-based imaging in
ED fellow 9 (25)
ICU fellow 9 (25) acute pediatric stroke care, most centers have the resources
Neurocritical care attending 9 (25) to perform MRI overnight. However, only approximately
Pediattic stroke attending 8 (22) one-half of centers reported having an MRI technologist
Adult neurology resident 7 (19)
Adult stroke fellow 4(11) in-house overnight, which has the potential to delay imaging
Adult stroke attending 3) while waiting for the technologist to travel to the hospital.
Neurocritical care fellow 38) Based on published data, this does not appear to influence
Pediattic stroke fellow 26)
Other 18) the overall time to neuroimaging for a child with a suspected
Administration of IV-tPA (N = 34)° stroke. A children’s hospital that had to call in an MRI tech-
Bedside RN 17 60) nologist from home overnight reported a time to neuroimag-
General child neurology resident/fellow 7 (21)
ICU attending 6 (18) ing of79 minutes,“ while another children’s hospital with an
Pediatric stroke attending 6 (18) MRI technologist available in-house 24/7 reported a time to
Pharmacist 6 (18) neuroimaging of 82 minutes,'* suggesting that the overnight
ICU fellow 5 (15)
Neurocritical care attending 5 (15) location of the MRI technologist might not have a significant
Adult neurology resident 4 (12) effect on the time to neuroimaging. However, the number of
‘Adult stroke fellow 4 (12) overnight scans was not reported for the institution that calls
ED attending 4 (12)
General child neurology attending 4 (12) in an MRI technologist from home. In both cases, the pro-
Pediatric stroke fellow 26) portion of patients who underwent MRI as their initial imag-
Adult stroke attending 18) ing was similar, at 76% and 85%, respectively. Similarly, most
ED fellow 18)
Neurocritical care fellow 18) centers can obtain a sedated MRI overnight, with more anes-
ED resident 0 thesiologists than MRI technologists in-house after hours.
Thrombectomy Whether the need for sedation increases the time to neuroi-
Thrombectomy performed after6 h (N = 25) 16 (64)
Availability of NIR (N= 36)" maging remains a matter of debate, with some studies
Pediatric NIR during business hours 26) showing no impact'*“° but others suggesting that the need
Pediatric NIR 24/7 9 (25) for sedation contributes to delays in obtain-
NIR at adjacent adult hospital during business hours 18 (60)
NIR at adjacent adult hospital after business hours 19 63) ing neuroimaging.'*
Transfer for all NIR 7 (19) Another important component of a pediatric acute stroke
Transfer for NIR after business hours 18) response is the ability to administer or rapidly transfer a pa-
Other 4(11)
tient for hyperacute therapies, including IV-tPA and me-
‘MIR, neurointerventional radiology; AN, registered nurse. chanical thrombectomy. In contrast to adult stroke
“More than 1 response permitted.
management, most centers require confirmation of an infarct
before administering IV-tPA to a child. This underscores the
confirmed stroke, neuroimaging allows the treating team to importance of MR-based imaging in a child with a suspected
obtain information necessary for making acute management stroke. Interestingly, although the TIPS trial required visual-
decisions. Our survey confirms that MR-based imaging is ization of a vessel occlusion or thrombus as a prerequisite for
preferred over CT-based imaging.’” the administration of IV-tPA,’? fewer than one-half of cen-
For a child who presents <6 hours after symptom onset, ters in the present survey continue to require a vessel cutoff
the goals of acute neuroimaging often can be accomplished before administering IV-tPA to a child. For centers that do
using an abbreviated MR-based imaging protocol that in- require a vessel cutoff, acute vascular imaging becomes
cludes DWI, susceptibility-weighted or gradient recalled important not only for consideration for mechanical throm-
echo imaging, fluid-attenuated inversion recovery, and bectomy, but also for IV-tPA administration.
time of flight MR angiography of the head. This is what is rec- More than one-half of centers reported performing a
ommended by the International Pediatric Stroke Study Neu- thrombectomy in the past year, with most performing at least
roimaging Subgroup’ and is consistent with most centers’ 1 mechanical thrombectomy in a child >6 hours after symp-
acute stroke imaging protocols. Two studies that examined tom onset. Although diagnosing and treating stroke as
the sensitivity of abbreviated imaging protocols for pediatric rapidly as possible remains the overarching goal,’
224 Harrar et al
March 2022
mechanical thrombectomy within an extended time window
opens the door for a greater number of children to benefit
from hyperacute therapy. Caregiver recognition and delays
in seeking medical care remain important obstacles to the
rapid diagnosis and = management of __ pediatric
stroke.'?'*!>°> Extending the time window for acute treat-
ment beyond 4.5-6 hours makes it likely that more children
will be eligible for acute treatment. Nonetheless, we acknowl-
edge the controversy surrounding the use of hyperacute ther-
apies in children, with the most recent American Heart
Association/American Stroke Association scientific state-
ment on the management of stroke in children stating that
“whether and how to apply these therapies in childhood
remain controversial.”
A key component of an acute stroke response protocol is a
multidisciplinary team. At nearly all centers, multiple spe-
cialties are involved in the acute care of a child with a sus-
pected stroke. This likely reflects the centrality of
neuroimaging to the rapid diagnosis of a child with a sus-
pected stroke. To accomplish timely neuroimaging, spe-
cialties such as radiology and anesthesiology become key
players, and this is reflected in the number of institutions
that include radiologists and imaging technologists in stroke
alert pages.
At several institutions, adult neurologists are the first pro-
viders from neurology to evaluate a child with a suspected
stroke. In some cases, this may reflect a partnership with an
adjacent adult hospital that may in turn allow for more rapid
evaluation of a child with a suspected stroke, because adult
hospitals typically have a resident in-house 24/7. Unfortu-
nately, not all freestanding children’s hospitals are in the vi-
cinity ofan adult hospital, and indeed, when considering the
pediatric neurology response to a child with a suspected
stroke after hours, most first responders are at home. This
is a potential contributor to delays in diagnosis and suggests
that having robust systems in place for initial evaluation and
triage independent of the neurologist being present at
bedside may be important.
Many centers rely on the neurointerventional radiology
team at an adult hospital for performance of mechanical
thrombectomy, suggesting another potential benefit of a close
partnership with an adult hospital. For those children’s hospi-
tals without an adjacent adult hospital or a pediatric neuroin-
terventional radiologist available to perform mechanical
thrombectomy 24/7, it becomes necessary to transfer patients
to other institutions for mechanical thrombectomy. In this
case, it is important to have a preestablished protocol to facil-
itate safe and rapid transfer of patients to the hospital best
equipped to provide comprehensive care.'”
Many institutions have only 1 stroke specialist on staff.
Although staffing outside of an alert was not specifically
queried, this raises the possibility that this individual is
involved in the care of many, if not all, of the patients who
present with suspected stroke. Based on free text responses,
at some institutions the pediatric stroke neurologist is indeed
always on call for acute stroke care. This suggests a potential
need for an increased number of pediatric stroke specialists,
Pediatric Acute Stroke Protocols in the United States and Canada
ORIGINAL ARTICLES
although consideration needs to be given to how best to
educate these individuals, given the relative paucity of pedi-
atric stroke training programs. This finding also suggests that
pediatric stroke neurologists may be guiding the care of these
children without formal reimbursement, especially at those
institutions without a stroke consult service, indicating a
value-add of the pediatric stroke neurologist that may not
be appreciated if that value is assessed using traditional
means, such as work relative value units.
We anticipate continued rapid advancement in acute pedi-
atric stroke care. Central to that advancement will be the abil-
ity to diagnose children with suspected stroke efficiently and
to standardize acute stroke practices in a manner that is
consistent with evidence-based guidelines’'' and mindful
of institutional resources. The implementation of pediatric
acute stroke protocols has allowed for marked improvements
in our ability to rapidly diagnose children with stroke. As
more centers develop and implement acute stroke protocols,
it is important to consider how best to integrate those proto-
cols into existing institutional structures. The survey re-
sponses reported here provide insight into how to
implement a stroke protocol taking into consideration
various local staffing structures and resource availability.
We anticipate that this will greatly aid those centers that
wish to develop or optimize standardized practices in acute
stroke care, which in turn will allow for future comparative
effectiveness and other studies aimed at identifying care stra-
tegies that improve patient outcomes.
A Canadian group recently examined hyperacute arterial
ischemic stroke pathways at the 16 tertiary pediatric hospitals
in Canada, with the goal of understanding similarities and
differences between stroke protocols." Seven of the hospitals
(44%) have an established stroke protocol, and 2 (13%) have
a protocol under development. The difference between that
study and our present study in the percentage of responding
institutions with a stroke protocol likely reflects the fact that
our sample was derived from institutions that participate in
large pediatric research networks focused on pediatric stroke
and neurocritical care. It is also possible that institutions with
a stroke pathway were more likely than those without a stroke
protocol to respond to our survey, further biasing our sample
in favor of institutions with an established stroke pathway.
Similar to our data, the Canadian survey revealed consider-
able interinstitutional heterogeneity in terms of staffing and
other practices relating to pediatric stroke pathways (eg,
preferred imaging modality, time frame for eligibility for me-
chanical thrombectomy), further demonstrating the signifi-
cant variability in current acute pediatric stroke care.
The American Heart Association/American Stroke Associ-
ation 2018 Guidelines for the Early Management of Patients
with Acute Ischemic Stroke, which are geared toward adult
stroke, also emphasize areas of focus similar to those
included in our survey, including having an organized proto-
col for the emergency evaluation of patients with suspected
stroke and having a designated acute stroke team that in-
cludes physicians, nurses, and __laboratory/radiology
personnel.” It is recommended that a stroke severity rating
225
THE JOURNAL OF PEDIATRICS « www.jpeds.com
scale—preferably the National Institutes of Health Stroke
Scale—be used, and that all patients with suspected acute
stroke undergo brain imaging on arrival to the hospital.
Goal times for imaging are within 20 minutes of arrival in
the ED for at least 50% of patients who may be candidates
for IV-tPA and/or mechanical thrombectomy, and goal times
for IV-tPA administration are within 60 minutes in 250% of
eligible patients with acute ischemic stroke. Goal times for
imaging in children reported by respondents to our survey
are longer than this, with 60 minutes the most common.
This may reflect the preference for MR-based imaging in chi
dren and is in keeping with the shortest times from ED arrival
to neuroimaging reported in the literature.’'” The guide-
lines also emphasize that centers have the ability to perform
emergency noninvasive intracranial vascular imaging to
select patients for transfer for endovascular intervention, if
not performed locally, and to reduce the time to thrombec-
tomy. In keeping with this, most respondents to our survey
include noninvasive angiography as part of their initial imag-
ing. It is also noted that protocols for interhospital transfer of
patients should be established and approved beforehand so
that efficient patient transfers can be accomplished at all
hours of the day and night. Although not queried in our sur-
vey, this seems to be of especial relevance in pediatrics, given
the reliance on adult hospitals for performance of mechanical
thrombectomy.’” It is also emphasized that in all cases, the
benefit of therapy is time-dependent and treatment should
be initiated as quickly as possible, reflecting the importance
of having systems of care in place that allow for the efficient
diagnosis and management of patients with acute stroke.
We acknowledge several limitations of our study. First, as
an Internet-based survey study, it is subject to reporting
bias. The survey was distributed to individuals who partic-
ipate in 2 large pediatric research networks for sample con-
venience, and there may be institutions with stroke alert
protocols that did not receive the survey or chose not to
complete it. Given that we did not request identifying infor-
mation, we are unable to determine how many of the largest
pediatric institutions in the US and Canada are represented
among our survey respondents. Moreover, although we re-
quested that only 1 survey be completed per institution, it is
possible that multiple surveys were completed at a sin-
gle institution.
In summary, an acute stroke response protocol is utilized
in at least 41 pediatric centers in the US and Canada. Most
acute stroke response teams are multidisciplinary, have
annual experience providing IV-tPA and mechanical throm-
bectomy, and prefer an abbreviated MRI over CT for stroke
diagnosis. Further studies are needed to standardize prac-
tices of pediatric acute stroke diagnosis and hyper-
acute management. ll
We thank the members of the International Pediatric Stroke Study and
the Pediatric Neurocritical Care Research Group who responded to our
survey.
Submitted for publication Jul 6, 2021; last revision received Oct 13, 2021;
accepted Oct 26, 2021
226
Volume 242
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THE JOURNAL OF PEDIATRICS « www.jpeds.com Volume 242

Table I. Institutional and stroke program

demographic characteristics
Characteristics n(%)
Hospital (N = 47)*
Free-standing children's hospital 32 (68)
Children's hospital embedded in adult 10 (21)
hospital
‘Academic/university-based 19 (40)
Private/community 0
Government/county 0
Other 0
Location (N = 47)
Northeast 7 (15)
Midwest 13 (28)
South 1480)
West 10 (21)
Canada 36)
ED visits per year (N = 35)
0-10000 0
10001-20000 7 (15)
20001-30000 26)
30001-40000 3Q)
40.001-50 000 3Q)
>50 000 19 (54)
Other 18)
Cardiac and pediatric ICU beds (N = 46)
0
8(17)
18 (39)
11 (24)
6 (13)
37)
Number of neurologists (N = 42)
0-5 1@)
6-10 15 (36)
11-20 11 (26)
21-40 8 (19)
>40 5 (12)
Number of child neurology trainees per
year (N = 44)
3(7)
6 (14)
13 (30)
9 (20)
6 (14)
2(5)
5 (11)
Number of neurologists with expertise in
pediatric stroke (N = 42)
10 (24)
15 (36)
7(17)
26)
6 (14)
266)
Inpatient stroke consult service (N = 45) 19 (42)
Availability of stroke consult service
(N=17)
In-person 24/7 7 (41)
In-person during day, by phone 963)
overnight
Other 16)
Type of consults seen by stroke service
(N=17)"
Hyperacute 17 (100)
Nonhyperacute 1165)
Stroke clinic (N= 42) 31 (74)
Stroke training program (N = 42) 9(21)
ICU, intensive care unit.
*More than 1 response permitted.

227.e1 Harrar et al
March 2022 ORIGINAL ARTICLES

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Pediatric Acute Stroke Protocols in the United States and Canada 227.e2
THE JOURNAL OF PEDIATRICS « www.jpeds.com Volume 242

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Figure 1. Continues
SS

227.e7 Harrar et al