Abstract 37: Pediatric Brain Attacks: Differentiating Between Stroke and Mimics in the Emergency Room.

Abstract

Objective: Timely recognition of stroke in the pediatric emergency room (ER) is critical to improving access to hyper-acute therapies. We aimed to identify key clinical features which discriminate between stroke and non-stroke brain attacks (mimics). Methods: Two-hundred and eighty consecutive children presenting to the ER with non-stroke brain attacks, prospectively recruited over 18 months in 2009-2010, were compared to 104 children with stroke, prospectively/retrospectively recruited from 2003-2010. Brain attack was defined as acute onset focal brain dysfunction with ongoing symptoms or signs on arrival to the ER. Exclusion criteria included known epilepsy, hydrocephalus, head trauma and isolated headache. Results: Stroke diagnoses included arterial ischemic stroke (AIS) (55), hemorrhagic stroke (HS) (37), TIA (10) and sinovenous thrombosis (2). The most common mimic diagnoses included migraine (87), first seizure (46), Bell’s palsy (29) and conversion disorder (18). Children with stroke were more likely to have sudden onset of symptoms (85% vs. 71%), arrive by ambulance (63% vs. 33%) and receive higher triage category (43% vs. 23%) than mimics (p<0.001 all variables). Symptoms with good discriminatory value (stroke vs. mimic) included focal weakness (58% vs. 34%), altered consciousness (31% vs. 19%) and speech disturbance (36% vs. 16%) (p<0.001 all variables). Signs with good discriminatory value included focal weakness of the face (45% vs. 14%), arm (47% vs. 13%) or leg (38% vs. 15%), dysarthria (22% vs. 5%), dysphasia (11% vs 3%) and altered consciousness (43% vs. 23%) (p<0.001 all variables). Absence of focal neurological signs (20% stroke vs 35% mimic) on examination predicted mimic (p=0.005). Conclusions: Focal weakness and speech disturbance predict stroke diagnosis in children with brain attack symptoms, findings which are similar to adults. These findings will inform the development of pediatric bedside stroke recognition tools to improve rapid recognition of stroke by emergency physicians.