In 2017, a system for acute triage and evaluation of children with suspected stroke was implemented in eastern Denmark. A recent evaluation shows that the system works as intended and not only identifies children with stroke but also children with other acute neurological disorders.
While a stroke is usually thought about in connection with adults, it can occur in children as well.
Children may experience stroke due to infections or congenital heart defects, but stroke may also occur in otherwise healthy children who develop a tear in the lining of an artery due to head or neck trauma.
In Denmark, stroke occurs in 30–60 children each year leaving 40–60% with long-term disabilities, including epilepsy, muscle weakness and speech disturbances.
Rapid diagnosis and treatment can be decisive for these children’s prognosis. Unfortunately, the diagnosis of stroke in children is often delayed due to a lack of systematic approaches for acute triage and evaluation of children with suspected stroke symptoms.
This has now changed. In 2017, a new system for acute triage and evaluation of children with suspected stroke was implemented in eastern Denmark.
In a new study, researchers investigated how many children with stroke or other acute stroke-like conditions who were assessed through the system.
“Before 2017, we had no systematic regional scheme for acute triage of children with suspected stroke. Now we do, and our study shows that the system works as intended,” says a researcher behind the study, Julie Brix Bindslev, PhD Fellow, Department of Neurology, Rigshospitalet, Copenhagen.
The research has been published in the European Stroke Journal.
Acute system activated by a phone call
The system is activated by a phone call to a specially trained vascular neurologist at the Comprehensive Stroke Center at Rigshospitalet in Copenhagen.
The calls usually come from the emergency department doctors, paediatricians, paramedics and urgent care doctors.
The vascular neurologist assesses whether the child’s symptoms are compatible with a stroke and whether the child is eligible for acute revascularisation treatment.
Children meeting these criteria are directly and urgently transferred to the University Hospital of Copenhagen, Rigshospitalet. On arrival, the child is evaluated by a paediatric stroke team consisting of a neurologist, a paediatrician and an anaesthesiologist. If stroke is suspected, the child will undergo urgent neuroimaging with MRI or CT and CT-angiography.
When a stroke is identified within 4.5 hours, some children can receive acute revascularisation treatment with medication that breaks up the blood clot (intravenous thrombolysis). Furthermore, children diagnosed within 24 hours from stroke onset can sometimes be treated with endovascular recanalisation therapy, in which the blood clot is removed through a catheter inserted into the groin.
“Since paediatric stroke is rare, few paediatricians are accustomed to providing acute stroke treatment. In contrast, neurologists treat many stroke patients. The interdisciplinary collaboration benefits from competencies across the specialties, which is essential when a child has a stroke,” says Julie Brix Bindslev.
Identified the expected number of children with stroke
The researchers investigated how many children with stroke were referred through the system between January 2020 and December 2021.
“Based on previous studies, we estimated that 12 children in eastern Denmark would develop an ischaemic stroke during the 24-month study period. We compared this estimate with the actual number of children with ischaemic stroke who were referred through the system,” explains Julie Brix Bindslev.
The researchers found that during the study period, there were 166 calls to the vascular neurologists regarding children with a suspected stroke. Among these, 15 had a stroke, of which 10 had ischaemic stroke. Two children were eligible for revascularisation treatment with intravenous thrombolysis and endovascular therapy. Both were triaged to the Comprehensive Stroke Centre and received the treatments.
Julie Brix Bindslev describes that the researchers expected that most children referred to the vascular neurologists would have other conditions than stroke.
“No healthcare professional wants to overlook stroke in a child. In addition, distinguishing stroke from other acute neurological conditions can be difficult in the acute phase, where neuroimaging has not yet been performed,” she says.
Identified many other diseases
Another important finding is that the system not only identified children with stroke but also children with other acute neurological disorders such as brain tumours, multiple sclerosis, infections of the nervous system and epileptic seizures.
“Twenty percent of the 166 children referred through the system had other acute diseases. Thus, our study shows that the new system not only benefits children with stroke but also children with other acute neurological disorders,” explains Julie Brix Bindslev.
The system was developed in close collaboration between the ambulance service, neurologists, neuroradiologists, paediatricians, anaesthesiologists and neurosurgeons at the University Hospital of Copenhagen, Rigshospitalet.
Although the system was implemented in 2017, it is continually adjusted. The results of the new study will be used for the ongoing adjustment.
“Twice each year, researchers and physicians at Rigshospitalet meet to discuss the quality of the system and strategise to improve quality and outcomes for the patients,” describes Julie Brix Bindslev.
