Standardizing care of childhood stroke: a call to action for clinicians and researchers

The past 20 years have seen a 35% increase in the prevalence of paediatric stroke.1 The majority of survivors experience long-term impairments, yet the nature, severity, and functional consequences of childhood stroke are poorly characterized.2 The Royal College of Paediatrics and Child Health childhood stroke guidelines provide a comprehensive evidence-based approach to diagnosis and clinical management, along the child's journey from initial presentation, through to rehabilitation and beyond (http://www.rcpch.ac.uk/stroke-guideline). The guidelines are, therefore, very relevant to health professionals working in prehospital, acute care, rehabilitation and educational settings. Major strengths include broad representation of key stakeholders and the use of validated methods to evaluate and grade the quality of evidence. A Delphi methodology was used to formulate consensus-based recommendations for important questions including thrombolysis, where evidence is lacking, and workshops were conducted to consider the perspectives of carers and young people affected by childhood stroke. The importance of a multidisciplinary team approach and good communication with families is emphasized at all stages of the child's management.

Inclusion of haemorrhagic stroke is a substantial improvement from the first edition published more than 12 years ago, given the higher associated mortality and economic cost than ischaemic stroke.3 The varied conditions associated with childhood stroke, which differ from adults, are presented. Specific recommendations are provided for important conditions associated with high risk of initial or recurrent stroke, including sickle cell disease, Moyamoya, and vascular malformations. The International Classification of Functioning Disability and Health (ICF) is used as framework to allow identification of rehabilitation interventional targets, considering the impact of stroke on the developing brain.

Limited evidence is a major limitation of the guidelines, with most recommendations based on consensus opinion of the guideline development group. Evidence is lacking for stroke unit care, intravenous thrombolysis, and endovascular therapies. These are the three interventions which have transformed outcomes for adults with ischaemic stroke. Obstacles to accessing hyperacute therapies include poor clinical recognition by parents, prehospital and emergency care providers, and the logistical challenges to rapid diagnostic brain imaging. It is likely that these factors contributed to the lack of patient accrual in the Thrombolysis in Pediatric Stroke (TIPS) study, a multinational initiative which was designed to determine the dosage and safety of tissue plasminogen activator (tPA).4 Despite limited evidence, the guidelines provide consensus based recommendations for off-label use of tPA in children, adopting the inclusion and exclusion criteria developed by TIPS investigators.

The recommendation of computed tomography (CT) as the first imaging modality within 1 hour of symptom onset, to facilitate rapid diagnosis, may be influenced by consideration of what is achievable versus optimal within the National Health Service (UK), where only 23 paediatric neuroscience centres service a population of over 60 million people. Children with brain attacks are more likely to initially present to district general hospitals, where access to rapid magnetic resonance imaging (MRI) is challenging in the emergency setting. However, the evidence presented from this country5 and overseas indicate that CT has lower sensitivity than MRI for detection of acute ischaemia, particularly within the potential time window for hyperacute interventions. It is difficult to envisage how this approach will increase access to thrombolysis. Regional strategies will clearly be required to improve coordination of acute care in the pre-hospital and emergency department settings.

The guidelines provide an important opportunity to develop national clinical networks to standardize management along the continuum of care, to establish national registries with centralized prospective data collection for auditing of current practice, and to determine the efficacy and safety of acute therapies. A national research agenda is required to identify key priorities and to bridge the knowledge gaps identified by critical appraisal of the literature. The importance of multicentre research collaboratives to translate knowledge to practice cannot be over-emphasized. Both approaches require commitment of substantial organizational and financial resources from government and research funding bodies, to ensure children are not being left behind by evidence-based advances in adult stroke care which minimize brain injury and maximize long-term recovery.