Ischemic Stroke Evaluation and Management

Pathway Background

Stroke is a neurological injury caused by the occlusion or rupture of cerebral blood vessels.  Strokes can be ischemic, hemorrhagic, or both. Ischemic stroke is most frequently caused by arterial occlusion, but may be caused by venous occlusion of cerebral veins or sinuses.   Hemorrhagic stroke is the result of bleeding from a ruptured cerebral artery or at the site of arterial ischemic stroke.  

A stroke usually implies some type of injury to the brain that carries lasting consequences. Etiologies and risk factors for ischemic stroke include: cardiac abnormalities, vascular lesions, hematologic abnormalities, infections, head and neck trauma, genetic conditions, vasculopathy, illicit drugs, pregnancy, hypertension, hypercoagulable states, infections, and medications.  Clinical presentation varies based on age, etiology and stroke location.  Knowing the signs and symptoms to facilitate early initiation of treatment will minimize acute brain injury and maximize patient recovery.
 

Objectives

  • Recognize children with signs and symptoms of stroke
  • Establish a team approach for rapid evaluation, immediate treatment, in-hospital management, and discharge treatment and education.
     

Algorithm   Educational Module

  • % patients with pathway order set utilization 
  • Time to arrival to MD assessment (minutes) 
  • Time from arrival to MRI/CTA (minutes)
  • Time from arrival to treatment (tPA; minutes)
  • Average length of stay (days for inpatient; minutes for Emergency Department) 
     
  • Centers for Disease Control and Prevention (2011). A summary of primary stroke center policy in the United States. Atlanta: U.S. Department of Health and Human Services, retrieved from https://www.cdc.gov/dhdsp/pubs/docs/Primary_Stroke_Center_Report.pdf
  • Ferriero, D. M., Fullerton, H. J., Bernard, T. J., Billinghurst, L., Daniels, S. R., Debaun, M. R., …Smith, E. R.  on behalf of the American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing, (2019) Management of Stroke in Neonates and Children, A Scientific Statement From the American Heart Association/American Stroke Association, American Heart Association Journal, 50:e51–e96. doi: 10.1161/STR.0000000000000183 
  • Fox, C., (2019). Ischemic Stroke in Children and Young Adults: Etiology and Clinical Features, Literature review current through: Jun 2019. Retrieved from https://www.uptodate.com/contents/ischemic-stroke-in-children-and-young-adults-epidemiology-etiology-and-risk-factors
  • Ichord, R. N., Bastian, R., Abraham, L., Askalan, R., Benedict, S., Bernard, T. J., …Jawad, A. F., (2011) Inter-rater Reliability of the Pediatric NIH Stroke Score (PedNIHSS) in a Muticenter Study. Stroke, NIH Public Access,  42; 613-17. doi: 10.1161/STROKEAHA.110.607192, http://stroke.ahajournals.org/content/42/3/613.abstract
  • Lopez-Vincente, M., Ortega-Gutierrez, S., Amlie-Lefond, C., Torbey, M. T., (2010). Diagnosis and Management of Pediatric Arterial Ischemic Stroke, Journal of Stroke and Cerebrovascular Diseases, 19 (3):175-183. doi:10.1016/j.jstrokecerebrovasdis.2009.03.013
  • Rivkin, M. J., Bernard, T. J., Dowling, M. M., Amlie-Lefond, C., (2016) Guidelines for Urgent Management of Stroke in Children, Pediatric Neurology, 56: 8-17
    http://dx.doi.org/10.1016/j.pediatrneurol.2016.01.016
  • Royal College of Paediatrics and Child Health, (2017) Stroke in childhood, Clinical guideline for diagnosis, management and rehabilitation. Retrieved from https://www.guidelines.co.uk/paediatrics/stroke-in-childhood/453257.articleretrived 
  • Rivkin, M. J., deVeber, G., Ichord, R. N., Kirton, A., Chan, A., Hovinga, C. A., …Amlie-Lefond, C., (2015).  Thrombolysis in Pediatric Stroke (TIPS) study, Stroke, NIH Public Access, 46(3): 880-885. doi:10.1161/STROKEAHA.144.008210 
  • Simma, B., Holiner, I., Luetschg, J., (2013) Therapy in pediatric stroke, Eur J Pediatric, 172:867–875. doi 10.1007/s00431-012-1863-9
     

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.