Objective: To assess the demographic characteristics and presenting symptoms in a cohort of pediatric patients with ischemic stroke and develop a tool to improve recognition of ischemic stroke at the institution and in the community. Methods: We conducted a retrospective review of children aged 1 month to 18 years with radiologically confirmed ischemic stroke admitted to the University of Kentucky between January 2013 and June 2020. Characteristics such as age, sex, and diagnosis were recorded. The FAST (Face, Arms, Speech) and BEFAST (Balance, Eyes, Face, Arms, Speech) mnemonics were applied to all patients. We then applied the FAST-S tool and used the novel BEFAST-S. FAST-S adds new onset seizure to the previously validated tool. Results: For the study period, we identified 158 cases. Most patients were ≥ 3 years of age (n=113) and most were male (n=96). About one third (31%, n=50) of presentations concerning for stroke had diagnosed ischemic stroke at time of discharge; the majority were ≥ 3 years of age (n=31). Strokes were commonly associated with trauma (24%, n=12) and infection (22%, n=11). Common mimics for stroke included seizure in the absence of stroke (30%, n=33), migraine (18%, n=20), and conversion disorder (13%, n=14). FAST and BEFAST each identified the same 30 patients as having ischemic stroke (60%), with 26 patients being ≥ 3 years of age. Inclusion of new onset seizures (FAST-S/BEFAST-S) correctly identified one additional patient ≥ 3 years of age (87%, n=27) and nine additional patients under 3 (n=19, 78% versus n=4, 21%). New onset seizure reduced the number of missed strokes regardless of age from 40% (n=20) to 16% (n=8). Conclusions: Although BEFAST improves the sensitivity of identification of ischemic strokes in adults, it did not identify additional strokes beyond FAST in our pediatric population. Inclusion of new onset seizure in addition to either FAST or BEFAST, however, reduced the number of missed strokes by at least half, particularly in children < 3 years of age. Thus, education of FAST-S or BEFAST-S may be useful for providers and emergency services.
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