Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2011 Delayed diagnosis of acute ischemic stroke in children - a registry-based study in Switzerland Martin, C ; von Elm, E ; El-Koussy, M ; Boltshauser, E ; Steinlin, M Abstract: QUESTIONS UNDER STUDY/PRINCIPLES: After arterial ischemic stroke (AIS) an early diagnosis helps preserve treatment options that are no longer available later. Paediatric AIS is difficult to diagnose and often the time to diagnosis exceeds the time window of 6 hours defined for thrombolysis in adults. We investigated the delay from the onset of symptoms to AIS diagnosis in children and potential contributing factors. METHODS: We included children with AIS below 16 years from the population- based Swiss Neuropaediatric Stroke Registry (2000-2006). We evaluated the time between initial medical evaluation for stroke signs/symptoms and diagnosis, risk factors, co-morbidities and imaging findings. RESULTS: A total of 91 children (61 boys), with a median age of 5.3 years (range: 0.2-16.2), were included. The time to diagnosis (by neuro-imaging) was <6 hours in 32 (35%), 6-12 hours in 23 (25%), 12-24 hours in 15 (16%) and >24 hours in 21 (23%) children. Of 74 children not hospitalised when the stroke occurred, 42% had adequate outpatient management. Delays in diagnosis were attributed to: parents/caregivers (n = 20), physicians of first referral (n = 5) and tertiary care hospitals (n= 8). A co-morbidity hindered timely diagnosis in eight children. No other factors were associated with delay to diagnosis. A total of 17 children were inpatients at AIS onset. CONCLUSIONS: One-third of children with AIS were diagnosed within six hours. Diagnostic delay was predominately caused by insufficient recognition of stroke symptoms. Increased public and expert awareness and immediate access to diagnostic imaging are essential. The ability of parents/caregivers and health professionals to recognise stroke symptoms in a child needs to be improved. DOI: https://doi.org/10.4414/smw.2011.13281 Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-56192 Journal Article Published Version Originally published at: Martin, C; von Elm, E; El-Koussy, M; Boltshauser, E; Steinlin, M (2011). Delayed diagnosis of acute ischemic stroke in children - a registry-based study in Switzerland. Swiss Medical Weekly, 141:w13281. DOI: https://doi.org/10.4414/smw.2011.13281 Original article | Published 19 October 2011, doi:10.4414/smw.2011.13281 Cite this as: Swiss Med Wkly. 2011;141:w13281 Delayed diagnosis of acute ischemic stroke in children – a registry-based study in Switzerland Charlotte Martina, Erik von Elmb,c, Marwan El-Koussyd, Eugen Boltshausere, Maja Steinlin on behalf of the Swiss Neuropediatric Stroke Registry study group1 a Medical Faculty, University of Zurich, Switzerland b Health Care Evaluation Unit, Institute of Social and Preventive Medecine, CHUV and University of Lausanne, Switzerland c German Cochrane Centre, Department of Medical Biometry and Medical Informatics, University Medical Centre, Freiburg, Germany d Department of Neuroimaging, University Hospital of Bern, Switzerland e Division of Neuropediatrics, University Children’s Hospital of Zurich, Switzerland f Division of Neuropediatrics, University Children’s Hospital of Bern, Switzerland 1 Swiss Neuropediatric Stroke Registry study group: RESULTS: A total of 91 children (61 boys), with a median Boltshauser Eugen MD, University Children’s Hospital, age of 5.3 years (range: 0.2–16.2), were included. The time Zurich, Switzerland, Capone Andrea MD, Cantonal to diagnosis (by neuro-imaging) was <6 hours in 32 (35%), Children’s Hospital, Aarau Switzerland, Fluss Joel MD, 6–12 hours in 23 (25%), 12–24 hours in 15 (16%) and University Children’s Hospital, Geneva, Switzerland, >24 hours in 21 (23%) children. Of 74 children not hos- Gubser Mercati Danielle MD, Neuchatel, Switzerland, pitalised when the stroke occurred, 42% had adequate out- Keller Elmar MD, Cantonal Hospital, Chur, Switzerland, patient management. Delays in diagnosis were attributed Müller Anita MD, Cantonal Hospital Münsterlingen, to: parents/caregivers (n = 20), physicians of first referral Switzerland, Ramelli Gian Paolo MD, Cantonal Hospital (n = 5) and tertiary care hospitals (n = 8). A co-morbid- Bellinzona, Switzerland, Roulet-Perrez Eliane MD, ity hindered timely diagnosis in eight children. No other Lausanne, University Children’s Hospital, Lausanne, factors were associated with delay to diagnosis. A total of Switzerland, Schmid Regula MD, Cantonal Hospital, 17 children were inpatients at AIS onset. Winterthur, Switzerland, Schmitt-Mechelke Thomas MD, CONCLUSIONS:One-third of children with AIS were dia- Cantonal Children’s Hospital, Lucerne, Steinlin Maja MD, gnosed within six hours. Diagnostic delay was predomin- University Children’s Hospital, Bern, Switzerland, Weber ately caused by insufficient recognition of stroke symp- Peter MD, University Children’s Hospital Basel, toms. Increased public and expert awareness and immedi- Switzerland, Wehrli Edith MD, University Children’s ate access to diagnostic imaging are essential. The ability Hospital, Bern, Switzerland, Weissert Markus MD, of parents/caregivers and health professionals to recognise Children’s Hospital, St. Gallen, Switzerland stroke symptoms in a child needs to be improved. Key words: acute ischemic stroke; diagnosis; children; Summary time lag; population-based registry QUESTIONS UNDER STUDY/PRINCIPLES: After ar- terial ischemic stroke (AIS) an early diagnosis helps pre- Introduction serve treatment options that are no longer available later. Paediatric AIS is difficult to diagnose and often the time to Arterial ischemic stroke (AIS) in adults is considered a ser- diagnosis exceeds the time window of 6 hours defined for ious health threat and requires urgent medical treatment. thrombolysis in adults. We investigated the delay from the Prompt diagnosis allows the therapeutic option of throm- onset of symptoms to AIS diagnosis in children and poten- bolysis within the time window of 3 to 6 hours after first tial contributing factors. symptoms. Alternatively, early anti-platelet therapy is ef- METHODS: We included children with AIS below 16 fective in improving the outcome after stroke [1, 2]. Pae- years from the population-based Swiss Neuropaediatric diatric AIS has severity and long-term outcomes similar to Stroke Registry (2000–2006). We evaluated the time those in young adults [3]. Two-thirds of children sustaining between initial medical evaluation for stroke signs/symp- AIS have neurological deficits that may result in life-long toms and diagnosis, risk factors, co-morbidities and ima- disability, thus critically impacting their potential develop- ging findings. ment [4–7]. Therefore, early diagnosis and treatment is as important in children as it is in adults. Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 1 of 6 Original article Swiss Med Wkly. 2011;141:w13281 The diagnosis of stroke depends on the suspicion of stroke Study population by lay persons and health professionals, and careful clinical We included infants and children aged 1 month to 16 years examination. In children, an early diagnosis is more diffi- residing in Switzerland and diagnosed with AIS in one of cult for several reasons: firstly, AIS is less frequent than the participating thirteen medical centres between January in adults. Population-based estimates of the incidence of 1st, 2000 and December 31st, 2006. We excluded children paediatric AIS range from 2 to 5 per 100,000 children/ with stroke in the perinatal or neonatal period up to 30 days year [5, 8], which is rare compared to the incidence of 264 after birth. per 100,000 adults/year [9]. Secondly, most parents are un- aware of possible stroke symptoms in children and health Study data professionals rarely consider stroke in their differential dia- Information extracted from the SNPSR dataset and the gnosis [10]. In the diagnostic work-up for children with medical records included: demographic data (sex, age at suspected stroke, other health conditions such as postictal time of stroke), known risk factors in child’s history (e.g. state, hemiplegic migraine and acute demyelinating en- infections, heart disease, head injury and migraine), risk cephalomyelopathy have to be considered [11]. Paediatric factors in the family history (e.g. first degree relative with stroke is more difficult to diagnose because the aetiology stroke, heart attack or thrombosis), clinical presentation and risk factors of stroke in children are very heterogen- of AIS as signs and symptoms (e.g. decreased conscious- eous and differ from those in adults [5, 12]. ness, headache, seizures, other sensory motor deficit, visual In adult stroke, considerable efforts have been made for problems / palsy of cranial nerves, aphasia, ataxia), type of early diagnosis and treatment [13–17]. Information cam- diagnostic imaging performed, and localisation of stroke. paigns aim at educating the general population to the signs Based on these data, we calculated the paediatric National and symptoms of stroke in order to shorten the delay in Institute of Health Stroke Scale (pedNIHSS) score. This seeking medical help and reduce the severity of resulting score reflects several brain functions including conscious- disability. Furthermore, emergency and acute care have im- ness, vision, sensation, movement, speech