Positive stroke scale screen

View The Full Pathway

Obtain noncontrast head CT (Class I) or rapid-sequence MRI (Class I)

Yes

No

Initial management for both ischemic and hemorrhagic stroke involves achieving hemodynamic stability. For ischemic strokes, preventing hypotension is a largely accepted practice, but aggressive treatment of hypertension is still controversial. Although studies have shown hypertension in the first 3 to 5 days after a stroke may be associated with higher levels of morbidity, some patients with arteriopathy may have baseline hypertension to compensate for poor brain perfusion; thus, aggressive antihypertensive management may do more harm than good, and worsen penumbra infarction. Treating and preventing hypoglycemia and hyperthermia (temperature >38°C) is recommended. It is prudent to arrange transportation early on to a tertiary pediatric hospital with access to pediatric neurosurgery, neurology, hematology, and/or interventional radiology, to help formulate a multidisciplinary approach. Types of treatment include, but are not limited to, IV tissue-type plasminogen activator (tPA) and intra-arterial tPA; endovascular thrombectomy; craniectomy; endovascular coiling; microsurgical clipping; and exchange transfusion for patients with sickle cell disease. Much of the data regarding tPA and endovascular thrombectomy have been extrapolated from adult studies, and applications for pediatric patients remain promising but in need of further research. Some studies show that ≤2% of pediatric patients with acute ischemic stroke in the United States are treated with tPA. Possible reasons for this may be because acute ischemic stroke is relatively rare in pediatric patients, and there is often a significant delay in diagnosis. Furthermore, these patients often have nonspecific symptoms, which may make their “last known well” time difficult to determine, making it challenging to reliably initiate treatment within 4.5 hours after stroke onset.

For hemorrhagic strokes, neuroprotective care to minimize secondary brain injury is imperative. Blood pressure management emphasizes the maintenance of adequate cerebral perfusion pressure in the setting of potentially increasing ICP; blood pressure reduction to help limit bleeding expansion has yet to be proven helpful in pediatric populations and specific blood pressure targets for children have not been defined. Maintain normoglycemia and normothermia with dextrose-containing fluids and non–nonsteroidal anti-inflammatory antipyretics or cooling blankets, respectively. Consider anticonvulsant medications and electroencephalogram monitoring, as children with intracranial hemorrhage are at high risk for seizures, which may be subclinical. In addition, immediately correct bleeding diatheses with blood transfusions for anemia, platelet transfusions for thrombocytopenia, factor replacement in patients with deficiencies (eg, hemophilia), and/or anticoagulant reversals in patients on anticoagulant medications. Avoid giving medications that could potentiate further bleeding. There are currently no surgical management guidelines for hemorrhagic stroke in pediatric patients. However, studies have shown that approximately 50% of pediatric patients with intracranial hemorrhage will require acute decompressive craniectomy and hematoma evacuation, largely due to neurologic deterioration (Glasgow Coma Scale score <8), impending brain herniation, hemorrhage located in the posterior fossa, or hydrocephalus. Discussion with a pediatric neurosurgeon is warranted in all cases of hemorrhagic stroke.

For more information on management of pediatric stroke, see the November 2019 issue of Pediatric Emergency Medicine Practice, “Pediatric Stroke: Diagnosis and Management in the Emergency Department.”