Hyperacute Treatment Research Articles

Pediatric Acute Stroke Protocols in the United States and Canada

To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures. 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. Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital 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 abbreviated 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. 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.

Telemedicine for stroke

The term “telestroke” was first introduced by Levine ad Gorman in 1999. Since then many telestroke networks have been developed throughout the world more than 22 in Germany alone, performing more than 38.211 teleconsultations per year. Most telestroke networks are organized in a hub and spokes system: one or several comprehensive stroke centers (hub), advise several regional or community hospitals (spoke) in stroke care. The degree of treatment possibilities in the spokes hospitals is highly variable; while some telestroke networks offer only hyperacute stroke treatment i.e. identifying strokes and performing thrombolysis onsite (TSRH-telemedicine-assisted Stroke Ready Hospitals), others have developed local stroke Units (TSU-Telemedical Stroke Units) and provide stroke care until the patient is discharged home/to a rehabilitation center. The backbone of every functioning telestroke network remains the implementation of standard operational procedures, regular staff trainings and quality management. Nowadays, telestroke is going far beyond thrombolysis and stroke unit treatment - the ultimate goal being to treat stroke patients from the beginning to the end remotely as close to the patients home as possible. Multiple telestroke projects target stroke from the onset to its rehabilitation and follow up care. To mention only a few, mobile stroke Units including CT scanners have brought thrombolysis to the patients front door, interventionalists are been flown by helicopter to regional hospitals to perform thrombectomy onsite, and patients are being discharged home with telerehabilitation programs. In conclusion, telestroke is a growing field, bringing qualitative and innovative stroke care closer to the patient.

Endovascular and thrombolytic treatment eligibility in childhood arterial ischemic stroke.

To describe factors affecting eligibility for, and rates of utilization of, hyperacute therapy in children with acute ischemic stroke (AIS) following establishment of our institutional acute stroke treatment pathway in 2005. A retrospective analysis of a prospectively enrolled, single-center cohort was performed including children age 2 - <18 years with acute AIS from 2005 through 2017. Descriptive statistics were used to summarize clinical characteristics, presentation data, and Pediatric NIH Stroke Scale (PedNIHSS) scores that were abstracted from medical records. Assessment for eligibility and administration of hyperacute therapy was determined at the time of presentation according to the institutional stroke pathway. Of 90 children (median age at presentation 11.3 years, 36% female) with acute AIS, 5 (6%) received hyperacute therapy: 3 received intravenous tissue plasminogen activator (IV-tPA) alone, 1 received endovascular therapy (EVT) alone, and 1 received IV-tPA and EVT. Of 54 children (60%) who presented within 4.5h of time last seen well, 6 had PedNIHSS scores 6-24, no medical contraindication to IV-tPA, and a partial or complete vessel occlusion. Of 7 children >3 years old who presented after EVT became available at our hospital and within 6h of time last seen well with a PedNIHSS score 6-24, 3 (43%) had a large vessel occlusion (LVO). Two patients underwent EVT and the other patient was not transferred until >6h from time last seen well. Delay to presentation and diagnosis of childhood acute AIS, mild neurologic deficits at presentation, medical contraindications to IV-tPA, and lack of vessel occlusion on acute neuroimaging contribute to low rates of hyperacute treatment in children with acute AIS.

Prognostic analysis of different therapeutic regimens in patients with acute cardiogenic cerebral embolism

BackgroundFew studies focused on the functional outcomes of patients at 3 months after receiving intravenous thrombolysis, anticoagulation, or antiplatelet therapy within 4.5 h of onset of the cardiogenic cerebral embolism (CCE) subtype.MethodsThe purpose of this retrospective study was to analyse the clinical data of patients with acute CCE and compare the 3-month functional prognoses of patients after administration of different antithrombotic therapies within 4.5 h of stroke onset. A total of 335 patients with CCE hospitalized in our institution were included in this study. The patients were stratified according to the hyperacute treatment received, and baseline clinical and laboratory data were analysed. A 3-month modified Rankin scale (mRS) score of 0–2 was defined as an excellent functional outcome.ResultsA total of 335 patients were divided into thrombolytic (n = 78), anticoagulant (n = 88), and antiplatelet therapy groups (n = 169). A total of 164 patients had a good prognosis at 3 months (mRS ≤ 2). After adjustments were made for age and National Institute of Health Stroke Scale (NIHSS) score, each group comprised 38 patients, and there were no significant differences in sex composition, complications, lesion characteristics, or Oxfordshire Community Stroke Project (OSCP) classification among the three groups. The plasma D-dimer level (µg/ml) in the thrombolytic group was significantly higher than those in the anticoagulant and antiplatelet groups [3.07 (1.50,5.62), 1.33 (0.95,1.89), 1.61 (0.76,2.96), P < 0.001]. After one week of treatment, the reduction in NIHSS in the thrombolytic group was significantly greater than those in the other two groups [3.00 (1.00, 8.00), 1.00 (0.00, 5.00), 1.00 (0.00, 2.00), P = 0.025]. A total of 47 patients (41.2 %) had an mRS score of ≤ 2 at 3 months, and 23 patients died (20.2 %). There was no significant difference in the proportion of patients with a good prognosis or the mortality rate among the three groups (P = 0.363, P = 0.683).ConclusionsThrombolytic therapy is effective at improving short-term and 3-month prognoses. Anticoagulant therapy may be a safe and effective treatment option for patients with the cardiac stroke subtype who fail to receive intravenous recombinant tissue plasminogen activator (r-tPA) thrombolysis within 4.5 h in addition to antiplatelet therapy, as recommended by the guidelines.

A Pilot Clinical Study of Hyperacute Serum Treatment in Osteoarthritic Knee Joint: Cytokine Changes and Clinical Effects.

The serum fraction of platelet-rich fibrin (hyperacute serum) has been shown to improve cartilage cell proliferation in in vitro osteoarthritic knee joint models. We hypothesize that hyperacute serum may be a potential regenerative therapeutic for osteoarthritic knees. In this study, the cytokine milieu at the synovial fluid of osteoarthritic knee joints exposed to hyperacute serum intraarticular injections was investigated. Patients with knee osteoarthritis received three injections of autologous hyperacute serum; synovial fluid was harvested before each injection and clinical monitoring was followed-up for 6 months. Forty osteoarthritic-related cytokines, growth factors and structural proteins from synovial fluid were quantified and analysed by Multivariate Factor Analysis. Hyperacute serum provided symptomatic relief regarding pain and joint stability for OA patients. Both patients “with” and “without effusion knees” had improved VAS, KOOS and Lysholm-Tegner scores 6 months after of hyperacute serum treatment. Synovial fluid analysis revealed two main clusters of proteins reacting together as a group, showing strong and significant correlations with their fluctuation patterns after hyperacute serum treatment. In conclusion, hyperacute serum has a positive effect in alleviating symptoms of osteoarthritic knees. Moreover, identified protein clusters may allow the prediction of protein expression, reducing the number of investigated proteins in future studies.

Abstract MP19: Reimbursement of Mobile Stroke Units in the United States: A Survey by the Prehospital Stroke Treatment Organization (PRESTO)

Background: Mobile Stroke Units (MSU) provide hyperacute diagnosis and treatment in the prehospital setting and are growing in number around the world. However, USA MSU reimbursement limits program proliferation and increases dependency on grants to support program costs. Therefore, we aimed to understand the USA MSU reimbursement paradigm. Methods: IRB approval was obtained for the conduct of an anonymous national MSU survey. Survey items were developed by MSU leaders experienced with reimbursement models and disseminated to all USA MSU programs. Returned data were entered and analyzed in SPSS using descriptive statistics. Results: Of the 20 existing USA MSU programs, 19 (95%) returned surveys. Programs work 26 + 6 (median 30) days per month serving a median 240 sq. mile radius with a median 600 dispatches per year; 47% describe their service area as metropolitan, 16% as rural, with 37% serving both. A median 4 people staff the MSU with 37% including an MD and 16% including an APP as the expert on board; the remaining programs use telemedicine MD coverage. Two programs are classified as “virtual ED” with 1 of these not classified as an EMS vehicle; 1 MSU is classified as an “outpatient clinic” with all other programs classified as EMS vehicles; 21% are certified CT Mobile Laboratories. During the last 12 months, overall the 19 responding programs gave on average 72 + 78 (median 30) alteplase tPA treatments. Of the 15 programs providing billing practices, 47% bill EMS ALS charges; supplemental billing included CT (53%), critical care (5%), telemedicine (53%), tPA (21%), and labs (5%), however, collection was poor. Overall, programs described their financial performance as negative, with only 1 program (outpatient clinic) defining it as positive; 100% rely in part or totally on grants, philanthropy, or institutional support to sustain the program. Conclusion: USA billing restrictions challenge MSU financial sustainability limiting reimbursement to traditional EMS ambulance services. Given the importance of early MSU treatment to reduce disability and death, new financial models are needed to ensure the viability of MSU services.

Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study

BackgroundRebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood. MethodsA retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores. ResultsOf 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3–5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3–5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome. ConclusionsEarly rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.

A mixed methods randomised feasibility trial investigating the management of benign paroxysmal positional vertigo in acute traumatic brain injury

BackgroundTraumatic brain injury (TBI) is the leading cause of long-term disability in working age adults. Recent studies show that most acute TBI patients demonstrate vestibular features of dizziness and imbalance, often from combined peripheral and central vestibular dysfunction. Effective treatment for vestibular impairments post-TBI is important given its significant adverse impact upon quality of life and employment prospects. The most frequent peripheral vestibular disorder in acute TBI is benign paroxysmal positional vertigo (BPPV), affecting approximately half of acute cases. Although there is effective treatment for idiopathic BPPV, there are no high-quality clinical data for post-TBI BPPV regarding its prevalence, natural history, which treatment is most effective and when is the best time to treat. In particular, observational studies suggest post-TBI BPPV may be recurrent, indicating that hyperacute treatment of BPPV may be futile. Given the potential hurdles and the lack of accurate post-TBI BPPV data, the current study was designed to provide information regarding the feasibility and optimal design of future large-scale prospective treatment studies that would compare different interventions and their timing for post-TBI BPPV.MethodA multi-centre randomised mixed methods feasibility study design was employed. We aim to recruit approximately 75 acute TBI patients across a range of clinical severities, from three major trauma centres in London. Patients will be randomised to one of three treatment arms: (1) therapist-led manoeuvres, (2) patient-led exercises and (3) advice. Participants will be re-assessed by blinded outcome assessors at 4 and 12 weeks. Acceptability of the intervention will be obtained by patient interviews at the end of their treatment and therapist interviews at the end of the study. Primary outcomes relate to feasibility parameters including recruitment and retention rates, adverse events and intervention fidelity. We will also aim to provide a more accurate estimate of the prevalence of BPPV in TBI cases on the trauma ward.DiscussionThe multi-centre nature of our feasibility study will inform the design of a future prospective treatment trial of BPPV in acute TBI. Important parameters we will obtain from this study, key for designing a future prospective treatment study, include estimating the prevalence of BPPV in TBI patients admitted to UK major trauma wards, and elucidating both patient and care-provider barriers in delivering BPPV treatment.Trial registrationISRCTN, ISRCTN91943864. Registered on 10 February 2020.

Does prolonged emergency department length of stay(EDLOS) affect the outcomes of acute ischemic stroke patients?

The effect of emergency department length of stay (EDLOS) on outcomes of patients with acute ischemic stroke (AIS) remains largely unexamined. We aimed to investigate the association between EDLOS and outcomes in AIS patients. 618 AIS patients were enrolled. Baseline demographics, vascular risk factors, ED admission information, hyperacute treatment of AIS and stroke severity were collected. Stroke progression was defined as any new neurological symptoms/signs or any neurological worsening within 7days after stroke onset and poor prognosis was defined as modified Rankin Scale(mRS) scores>2 at 30day. The effect of EDLOS on stroke progression and prognosis was assessed. The median EDLOS was 2.5h (1.4-6.9h). On multivariable linear regression, presentation month between Apr. and Jun., admission at the ED between 7am to 3pm(P=0.036), transferring to stroke unit, receiving endovascular interventional treatment, onset on holidays, and progressive stroke were associated with shorter EDLOS(all P<0.05). A shorter EDLOS was significantly associated with an increased risk of stroke progression (P=0.007). Patients with the lowest EDLOS (≤1.35h) were 2-3 fold more likely to have stroke progression, compared with those with the highest EDLOS (>6.93h) (OR, 2.52; 95% CI, 1.29-4.93; P=0.043). However, no significant association between EDLOS and stroke prognosis was revealed. In AIS patients, shorter EDLOS was associated with the increased risk of stroke progression, possibly reflecting prioritized admission of more severely affected patients at high risk of stroke progression. EDLOS alone might be an insufficient indicator of stroke care in the ED.

Historical diagnostic and therapeutic changes of ischemic stroke based on the highly cited articles

Purpose: Stroke is a global economic burden of health, which means that it is critical to evaluate changes of optimal diagnoses and treatments. The aim of the study reported herein was to identify the most-cited articles in the field of ischemic stroke and assess their characteristics. Methods: We searched all included articles that had been cited more than 100 times using the “Cited Reference Search” in February 2016 from Web of Science Core Collection. Among a total of 2,651 articles, we excluded articles on basic science and which involved only hemorrhagic strokes and identified the top-100 cited articles on ischemic stroke. Results: The number of citations for the articles analyzed in this study ranged from 5,182 to 580. Most of the articles were published in The Lancet (25%) and Stroke (23%), and originated from the United States of America (n=44). Most of them were original articles (65%) and dealt with stroke risk factors (32%) and stroke management (30%). A novel study of hyperacute treatment involving recombinant-tissue plasminogen activator was described in the top-ranked article. Conclusion: Reviews on highly cited articles can help physicians identify trends in the diagnosis and treatment of ischemic stroke in the past. This bibliometric analysis can provide a unique perspective on historical developments in this field.

Impact of the COVID-19 pandemic on hyperacute stroke treatment: experience from a comprehensive stroke centre in Singapore.

The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread. We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange. This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected. We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p = 0.004, 95% CI 6.513 to − 2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable (p = 0.519, 95% CI − 1.605 to 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 h (-4 versus -4, p = 0.685) were largely similar between the pre- and during DORSCON orange periods. The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.Electronic supplementary materialThe online version of this article (10.1007/s11239-020-02225-1) contains supplementary material, which is available to authorized users.

Practice recommendations for neurovascular ultrasound investigations of acute stroke patients in the setting of the COVID-19 pandemic: an expert consensus from the European Society of Neurosonology and Cerebral Hemodynamics.

Background and purposePatients with acute ischemic stroke are at high‐risk for contracting COVID‐19 infection. Additionally, healthcare professionals including neurovascular ultrasound providers are also at risk of being infected by SARS‐CoV‐2 virus. Yet, preparedness to continue to guarantee hyperacute treatment is vital for patients outcome. In light of this situation, the European Society of Neurosonology and Cerebral Hemodynamic (ESNCH) appointed a task force to provide consensus recommendations for the performance of neurovascular ultrasound investigations in acute ischemic stroke during the COVID‐19 pandemic with the aim of protecting both patients and ultrasound providers.MethodsThe “ultrasound in acute stroke working group” of the ESNCH examined literature articles and reviews using the following key words: “corona virus” or “COVID‐19” or “SARS‐CoV‐2 virus”, and “acute stroke” or “cerebrovascular disease”, and “ultrasound”. Thereafter, a thorough discussion was conducted with the “education and guidelines working group” of the ESNCH.ResultsWe propose rapid up‐to‐date recommendations for healthcare personnel involved in the pre‐hospital and intra‐hospital assessment of stroke patients, with a particular attention to neurovascular ultrasound performance.ConclusionThe ESNCH provides a guidance summary for the performance of neurovascular ultrasound investigations in acute ischemic stroke in the time of COVID‐19.

Untreated Stroke as Collateral Damage of COVID-19: "Time Is Brain" Versus "Stay at Home".

For decades, neurologists have been advocating that anyone with acute focal deficits report immediately to the closest hospital’s emergency room. Major advancements in the hyperacute diagnosis and treatment of stroke have justified our call-to-action slogan of “Time is Brain”—faster therapy leads to superior outcomes. However, this mantra has been recently usurped by the catchphrase “Stay at Home” during the coronavirus disease 2019 (COVID-19) pandemic. Fewer patients are presenting to hospitals with acute stroke; our census is down. Presumably the etiology of this phenomenon is either strict “social distancing” that some people may misperceive to exclude even emergent situations, or fears of contracting the virus while hospitalized. In this Short Report, we describe the year-over-year drop in stroke volume (ischemic and hemorrhagic both) coinciding with a paradoxical rise in acute reperfusion therapies at our university hospital. These data imply that stroke patients with mild/moderate symptoms are most likely staying home, and not receiving urgent therapies, and correspondingly, only the most severely disabled stroke patients are ultimately seeking and receiving help. We must remind our patients and the general public that our services are essential and available, as stroke still remains a medical emergency, and carries a likely higher overall mortality risk than COVID-19. As neurologists, we also must be vigilant for the atypical presentations and varied etiologies of stroke associated with COVID-19 as well.

COVID-19 presenting as stroke

ObjectiveAcute stroke remains a medical emergency even during the COVID-19 pandemic. Most patients with COVID-19 infection present with constitutional and respiratory symptoms; while others present with atypical gastrointestinal, cardiovascular, or neurological manifestations. Here we present a series of four patients with COVID-19 that presented with acute stroke. MethodsWe searched the hospital databases for patients that presented with acute stroke and concomitant features of suspected COVID-19 infection. All patients who had radiographic evidence of stroke and PCR-confirmed COVID-19 infection were included in the study. Patients admitted to the hospital with PCR- confirmed COVID-19 disease whose hospital course was complicated with acute stroke while inpatient were excluded from the study. Retrospective patient data were obtained from electronic medical records. Informed consent was obtained. ResultsWe identified four patients who presented with radiographic confirmation of acute stroke and PCR-confirmed SARS-CoV-2 infection. We elucidate the clinical characteristics, imaging findings, and the clinical course. ConclusionsTimely assessment and hyperacute treatment is the key to minimize mortality and morbidity of patients with acute stroke. Stroke teams should be wary of the fact that COVID-19 patients can present with cerebrovascular accidents and should don appropriate personal protective equipment in every suspected patient. Further studies are urgently needed to improve current understandings of neurological pathology in the setting of COVID-19 infection.

COVID-19 and Stroke Risk: A Double Whammy

AbstractThe emphasis so far during the COVID-19 pandemic has been on the respiratory manifestations with little attention being given to neurological manifestations. Literature has shown multiple cases of stroke being associated with COVID-19. Thus, there is great interest in the role of the virus in stroke pathogenesis. Regarding hyperacute and acute stroke treatment, the routine guidelines for thrombolysis and thrombectomy are to be followed with emphasis on high suspicion of COVID-19 in stroke cases with respiratory symptoms or with contact/travel history. Secondary risk factor treatment for hypertension, diabetes, dyslipidemia is a must. We recommend continuing angiotensin converting enzyme 2 inhibitors/angiotensin II receptor blockers (ARBs) in those who are taking these medications as per evidence available. Mandatory lockdown has led to delay in presentation to the hospital with a decrease in thrombolysis due to ineligibility and a corresponding increase in primary thrombectomies being performed. Telemedicine could be an important tool to triage cases worthy of tertiary referral from other strokes and must be encouraged.

Enhancing teamwork to create a high-performance team in the acute stroke unit at Worcestershire Royal Hospital – quality improvement project

The acute stroke unit (ASU) in Worcestershire Royal Hospital has a multidisciplinary team including consultants, junior doctors, nurses, physiotherapists, occupational therapists, and speech and language therapists focusing on delivering hyperacute stroke treatment and rehabilitation. However, it is felt there are difficulties in multiple levels such as staffing issues, disorganised ward rounds and teamwork, lack of communication between teams, lack of local induction, hindering our multidisciplinary team to become a high-functioning team. This quality improvement project (QIP) focused on identifying the areas of improvement and …

Abstract TP364: Developing a Pediatric Ischemic Stroke Code Protocol at a Comprehensive Stroke Center: The Georgetown Experience

Background/ Issue: Epidemiologically, pediatric strokes are rare; therefore, index of suspicion is low and many cases are not recognized early enough to qualify for acute treatment. With this small patient population, many regions have yet to develop protocols and policies for acute pediatric stroke response. In the District of Columbia, MedStar Georgetown University Hospital (MGUH) is the only Joint Commission Accredited Comprehensive Stroke Center with a pediatric intensive care unit. Purpose: The purpose of our program was to develop institutional protocols for pediatric stroke patients who are candidates for hyper-acute treatment. Protocols focused on pediatric patients who presented through our emergency department or were transferred from other facilities within the time window for acute treatment. The protocols were established to ensure a clear process for physicians and staff to follow. Methods: An interdisciplinary group met to discuss modification of our current Adult Ischemic Stroke Code Protocol needed for a coordinated approach to pediatric stroke patients. The team members included the Stroke Coordinator, Stroke Nurse Navigator, Stroke Nurse Practitioner, Pediatric Neurologist, Medical Director of the Pediatric ICU, Manager of the Pediatric ICU, Pediatric Anesthesia, Medical Director of the Stroke Program, and the Emergency Department Team. Results: The interdisciplinary team was able to adapt a protocol using the Adult Ischemic Stroke Code Protocol. Key differences between the adult and pediatric stroke code work-flow consisted of including pediatric neurologists early in the decision process, pediatric nurses to assist with monitoring children, and pediatric anesthesia for assistance with imaging and/or endovascular intervention. The order sets were adjusted to include weight- based calculations for medications, age-based monitoring parameters, and specific pediatric needs. Conclusion: It is possible to develop a Pediatric Stroke Code Protocol based on the Adult Ischemic Stroke Code Protocol to include all modifications appropriate for pediatric care and still maintain the rapid work-flow that everyone is familiar with. It is essential to include all key stakeholders to ensure a smooth and safe process.

Recommendations on telestroke in Europe

This paper is an adapted translation of recommendations on telestroke provided by the European Stroke Organization. Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. An aim of the study is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organization on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organization stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organization stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).

Arterial Ischemic Stroke in the Pediatric Population

Recognizing childhood arterial ischemic stroke risk factors and presentation are extremely important for a prompt diagnosis and administration of hyperacute treatment requiring a high level of clinical suspicion. Stroke presentation in the pediatric population is not very specific, yet it is imperative to distinguish it from other mimics that may require different medical management. Vascular imaging studies, including MRA, CTA, and advanced neuroimaging techniques (eg, arterial wall imaging and CT/MR perfusion images) are extremely useful in the diagnosis of arterial ischemic stroke. This article offers a review of arterial pediatric ischemic stroke risk factors, clinical presentation, and the imaging appearance of the most common arterial ischemic stroke etiologies.Learning Objective: To recognize multiple risk factors, etiologies, and imaging presentations of pediatric arterial ischemic strokes.

A Stroke Alert Protocol Decreases the Time to Diagnosis of Brain Attack Symptoms in a Pediatric Emergency Department

To determine whether a stroke alert system decreases the time to diagnosis of children presenting to the emergency department (ED) with acute-onset focal neurologic deficits. We performed a retrospective comparison of clinical and demographic information for patients who presented to the ED of a tertiary children's hospital with acute-onset focal neurologic deficits during the 2.5years before (n=14) and after (n=65) the implementation of a stroke alert system. The primary outcome was the median time to neuroimaging analyzed using a Wilcoxon rank-sum test. The median time from ED arrival to neuroimaging for patients with acute-onset focal neurologic deficits decreased significantly after implementation of a stroke alert system (196minutes; IQR, 85-230minutes before [n=14] vs 82minutes; IQR, 54-123minutes after [n=65]; P<.01). Potential intravenous tissue plasminogen activator candidates experienced the shortest time to neuroimaging after implementation of a stroke alert system (54minutes; IQR, 34-66minutes [n=13] for intravenous tissue plasminogen activator candidates vs 89.5minutes; IQR, 62-126.5minutes [n=52] for non-intravenous tissue plasminogen activator candidates; P<.01). A stroke alert system decreases the median time to diagnosis by neuroimaging of children presenting to the ED with acute-onset focal neurologic deficits by more than one-half. Such a protocol constitutes an important step in ensuring that a greater proportion of children with arterial ischemic stroke are diagnosed in a time frame that enables hyperacute treatment.