In the U.S., about 3,000 children have a stroke each year. Yet, as pediatric neurologist Christine Fox, MD, MAS, notes, most parents don’t know that kids can have strokes, and more crucially, many pediatric providers are slow to consider stroke as a possible cause of certain symptoms. Fox, who is director of the UCSF Pediatric Stroke and Cerebrovascular Disease Center, explains which underlying conditions raise risk and offers insights on how a child with stroke may present and how symptoms can progress following a minor-seeming event. An advocate for pediatric stroke readiness, she shows the evidence for swift diagnosis and treatment – potentially avoiding lasting neurological deficits for the kids and financial hardship for their families – and gives resources and tips to help care facilities put a pediatric stroke plan in place.
Um, thank you so much for the introduction. My name is Christine Fox. I am a pediatric vascular neurologist and I lead the pediatric stroke and Cerebrovascular Disease Center at UCSF Benioff Children's Hospitals. Um, today, I'm gonna be talking about pediatric stroke, awareness, action and advocacy. So before we get started, um, just wanted to say no, I have no commercial financial relationships to disclose. I do have grant funding to study pediatric stroke, uh, ischemic, and hemorrhagic from the American Heart Association and the National Institutes of Health, and I will be discussing some therapeutics that are not FDA approved and are considered investigational, and I'll point those out um when we get to those areas. So, my primary goal at the end of today's webinar is really to raise awareness for pediatric stroke. Um, when I talk to, uh, people in the general population and also to my friends who are physicians or other pediatricians, a lot of times I get a question about, um, oh, I didn't know that children could have strokes. Uh, so one of the biggest barriers to treating a, a stroke in a child is really getting them in quickly, um, to get early diagnosis and early treatment. So raising awareness is something that's really important, um, and that's something I'm hoping to do through today's talk. Um, in the middle of the talk, I'll be talking a little bit about two cases, uh, in order to illustrate, uh, hyper acute management considerations for stroke in children. And at the end, I'm gonna talk a little bit about some of the barriers to care and what we are trying to do, um, as a hospital to assess those barriers and improve our systems of care. So just starting with a little bit of an overview of the epidemiology of pediatric stroke, um, A lot of times when I get questions about pediatric stroke, people are unaware that cerebrovascular disease is one of the top 10 causes of death in young people, so children and even young adults. About half of pediatric strokes are ischemic and the other half are hemorrhagic. And this is a little bit different than what we see in the elderly, where about 80% of strokes are ischemic. There is a distinction that we make between neonatal stroke that happens um in utero or around the time of birth. Neonatal strokes are considered a stroke that occur within the 1st 28 days of life, and a childhood stroke is a stroke that occurs anytime after the 28 days of life. Childhood ischemic stroke incident, depending on the study that you look at, um, is estimated to be between 2 and 13 per 100,000 annually. And that is roughly the same as um the uh the rates that we see pediatric brain tumors. Um, so, uh, it's an important thing to remember that strokes can happen in children. Today I'm primarily gonna be talking about childhood ischemic stroke. But I wanted just to put in one or two slides on perinatal stroke and hemorrhagic stroke, um, just so that we remember that those are important pieces as well. So, I'd mentioned that perinatal stroke was a stroke that occurs within the 1st 28 days of life, um. It's actually the most common time period, um, the, the week around the time of your birth is the most common and highest risk time for stroke throughout your lifetime, even including when you're older. It's estimated to be about 2 to 1 for 2 to 4000 live births, and pre presentation often is um seizures in a baby or encephalopathy, but many babies are initially asymptomatic and only as they grow older do they grow into their deficits showing a hemiparesis or cognitive problems as they um later in childhood. One of the reasons that I'm gonna be talking primarily about childhood stroke today is that um there's a higher risk of recurrence and different management for children or older children who have a stroke compared to infants. Unfortunately, for perinatal stroke, there's little risk of recurrence later in life unless congenital heart disease is present. About 50% of stroke in children is hemorrhagic. And oftentimes these are strokes that affect previously healthy children who have an unknown underlying brain vascular malformation. These are also important to diagnose quickly. They often, the bleeding itself can often cause quick and dangerous uh elevated intracranial pressure. Um, and brain AVMs, which is the most common cause of a non-traumatic hemorrhagic stroke, um, sometimes can recur even after a sur uh, even after a surgical resection. Aside from brain AVMs, other vascular malformations are the primary causes. It can be cavernous malformations, intracranial aneurysms, and there can also be genetic causes of hemorrhagic stroke. OK, so for the remaining time that we're talking today, I'm gonna be primarily talking about childhood ischemic stroke. And uh when I use the word stroke, I'll be primarily referring to children who are older, greater than 28 days of life, and children who have an ischemic stroke. So a little bit more about the epidemiology, um, there's estimated to be about 3000 children per year who have an ischemic stroke during childhood. We know that there are some children who are at higher risk for stroke, and the high risk populations really are children who have underlying uh hematologic or heart conditions, so congenital heart disease, or acquired heart disease, sickle cell disease, and a number of genetic syndromes that can cause uh arteropathies. Also, children who have um other genetic conditions or thrombophilia are at elevated risk. So while there is a laundry list that I can show in my next slide, um, I think one of the big takeaway points is that although we can identify high risk populations, many children who present for the first time with a an ischemic stroke were previously healthy with no past medical history at all. Um. If you look at larger studies, it's estimated that about 1/3 to 50% of the children who present with an ischemic stroke, um, had no past medical history. So when we do talk about the underlying conditions that can uh predispose a child to stroke, um, I can, you can generally break it down into a couple of different categories. Um, one is a category that where there is a problem or pathology of the blood vessels that lead either through the neck, um, or up into the brain. That could be dissection, it can be mouoid disease, there can be infection or vasculitis. Um, the other big category that we think about are underlying cardiac disease, whether that is acquired or congenital. And although we have a list of things that can predispose a child to stroke, in actuality, I usually think about these as um as overlapping problems. So there might be someone who has a genetic predisposition that causes a structural problem. Um, some of those genetic predispositions may also cause a thrombophilia or other hematologic problem, and another big category that affects both of these are acquired exposures. So we know, for example, that children who may have an underlying predisposition or not, can have a stroke when they are exposed to trauma causing, for example, a dissection, um, infection causing a problem with one of the blood vessels that lead to the brain. Uh, radiation for childhood cancers also can put a child at risk for stroke, um, later on in life, and certain drugs, again, particularly those that are treatments for cancer, um, may also increase the risk of stroke in children. When I talk about this again, I think it's important to recognize that many children who present with their first stroke, um, have no past medical history and really were considered previously healthy. And I primarily emphasize this because um oftentimes when a child shows up in the emergency setting, um, The fact that there is no underlying past medical history throws people off and um and then causes delays in diagnosis. So, what does a child look like when they present with a stroke? Um, in many cases, the presentation of a childhood stroke is much like stroke in adults. There is often a new onset focal deficit. Um, so, specifically a hemiparesis that causes weakness in the face and the arm or the face, arm, and leg. It might be a loss of vision or double vision, a loss of coordination, um, difficulty balancing, um, or difficulty speaking. In some children, they also may um look like they have altered mental status that can be either a change in level of consciousness or sometimes is a language deficit. The timing of the deficit onset is abrupt in about half of cases, so that's similar to adult stroke. What's dissimilar is that about 50% of children actually don't have exactly what seems to be an abrupt onset, but rather have a waxing or waning new onset focal deficit, um, or sometimes progressive. And that can be over hours. There are a couple of reasons for that. And primarily, that's because um children who have problems with a, an artery or an arteropathy um can have vessel narrowing that um changes the flow of blood flow and that may be dynamic over hours. In children, um, the onset of a stroke oftentimes is accompanied by a seizure, and that also is different from what we see in adults. So depending on the age of the child, um, there's about, about 30% will present with a seizure at the time of the stroke, and that's much more common at younger ages. Another difference with adults is that children who are old enough to tell us what they're feeling, often complain of a headache at the time of the stroke, about 30%. In adults, classically, a stroke is um is typically painless. So, um, It's important to acknowledge that the mimics of childhood stroke are actually more commonly seen than childhood stroke itself. And I say this primarily so that when we do see um a child who presents with a stroke mimic, that we keep stroke on the differential. So some of these I have listed here are some of the most common mimics that we hear. The first, of course, is a complicated migraine. So someone who presents with a headache, um, with new onset neurologic symptoms and particularly weakness or loss of sensation. And it's much more common for a child to have a complicated migraine than a stroke, but, um, remembering that in children, stroke can present with headache will help us remember that um stroke should be on the differential, especially if we're seeing a child who has a first time presentation of a complicated migraine. And I usually tell our trainees that someone who presents with a complicated migraine for the first time, um, deserves imaging of their brain to look for stroke. It's only after they have proven that complicated migraine is what's happening after having had it several times that we can say it's OK to forego the imaging. Um, any child who has a first time seizure who is presenting with a postictal todsparesis or weakness on one side of the body, um, should also have stroke on the differential. Um, The difference with children who have epilepsy, who typically have um a todd'sparesis or weakness on one side after their seizure, and those who presenting are are presenting for the first time, um, we should be thinking again about imaging anyone who is presenting with a first time seizure, who has neurologic symptoms after the seizure, that is not rapidly improving. And then finally, I've had a couple of cases of stroke affecting the cerebellum that got missed because the family at home thought it was simply the stomach flu. Um, so the child presents with nausea and vomiting and ataxia, but the ataxia was unnoticed because the child was in bed and never got up. And so it was only until a couple of days later as the child was getting up and trying to walk, um, that the uh the cerebellar stroke was noted. So for all of these cases, if stroke is on the differential, especially if it is a first time complicated migraine, a first time seizure with weakness on one side that doesn't improve, or nausea, vomiting, and ataxia, remember, stroke is on the differential. It's important to activate a code stroke. So I'll talk a little bit more about outcomes later on in the talk. Um, but just to frame the problem, the costs of childhood stroke are very high. Among survivors, about 50% of children who have a stroke have lasting deficits in cognition or language or motor function, and about a third of them will develop epilepsy over the ensuing decade or so. Um, economically, Stroke in children um also um incurs some high costs. So we know that the median care of the first year after stroke is higher in children than in adults who have a comparable severity of stroke. And it's harder to measure, but we know that there are an unrecognized loss of potential costs over a lifetime for a child who presents with a new chronic condition, um, who may have a longer period of dependence or not achieve a uh independence over a lifetime. So these are um a large number of potential costs, both for the children and for the adults who care for them. Um, so, just to illustrate this, many of the families that I take care of, um, When their child has a stroke, one of the parents ends up having a change in employment, either um stopping out of their jobs so that they can stay stay home and take care of the child or a loss of a job. So for all of these reasons, any interventions that reduce disability in a child with a stroke would have major lasting effects on the individual child, on their families, and on society. And so, I'd like to keep this in mind when we're thinking about some of the hyper acute management strategies that I that I will be talking about in the rest of our talk, because these are the best way that we know to reduce disability in adults who present with stroke. So I'm gonna start with two cases to illustrate um two hyper acute management strategies for stroke that are used in adults and by extension that we are now using in children. Um case one is illustrating um intravenous thrombolysis. So for both of these cases, these really are based on children that I've taken care of with some of the details changed. Um, so, This first is a 14 year old boy, um, who was a soccer player and uh has no past medical history of anything that made the family think of stroke, um, but did have some thrombocytopenia when he was younger. That wasn't been a problem for him recently. Um, he had no recent illness and no head trauma, and was playing a soccer game. When near the end of the soccer game, he suddenly felt, um, began to feel strange. His right side felt heavy, he wasn't playing well, um, and when his coach stopped and tried to see what was going on, he was having a little bit of difficulty, um, speaking. He came out of the game, um, but his symptoms improved quickly. He still had a headache and um, the game went on. It was near the end of the game, and, uh, he seemed like he was better, but out of caution they ended up calling the paramedics. By the time the paramedics came, all of his symptoms had resolved, but they decided to take him to the emergency room nearby for evaluation. And his mom recounts that um she was following the ambulance in her car on the way to the hospital, um driving without lights and sirens, and suddenly the ambulance uh put on the sirens and then took off. Um, and what had happened was that in the ambulance, he had abruptly developed a a right hemiplegia and wasn't able to speak. So I take this moment, um just to do a quick concept review about presentation of stroke in children versus adults. Again, um, the presentation often can be similar, but like this 114 year old boy, he did have a headache, uh, when he had his first symptoms. So looking back on it now, his first symptoms during the game were probably a transient ischemic attack or TIA. Um, he did not have a seizure. Uh, but he did have a little bit of a waxing and waning progression, so some symptoms that initially showed resolved and then uh progressed to an abrupt concept. And this graph on the side, um, actually just shows the probability of an acute seizure um is much higher in younger children by about the age of 5, or school age, that plateaus out to be about a 20% risk, um, in children, which again is much higher than in adults. So this 14 year old um presented without a seizure, which is more common, um, about 80% present without seizures at that age. So going back to case one, on arrival in the emergency room, um, the notes show that he had a dysarthia, he had a visual field cut, and he had a hemiparesis that affected his face, arm, and his leg, and he had a sensory loss. Pete's NIH stroke scale was calculated at 11, and he had uh this MR imaging um done that Showed diffusion restriction on the left side. This is the area of his stroke, and showed a um cutoff of the distal middle cerebral artery. There was no hemorrhage. So, I'm gonna take a minute just to talk about the initial pediatric stroke imaging, because this is a little bit different um approach than what we learned about uh how to approach um adult stroke when we were learning in medical school. Just as a reminder, in adults, a, an adult presenting with a stroke, um syndrome, uh, oftentimes can get just a head CT and evaluation or uh potential IV thrombolysis, um, at, at a minimum. Sometimes vascular imaging is added on in order to diagnose whether or not there is a vessel occlusion. Um, In pediatric stroke imaging, we often use uh MRI rather than CT. And because MRI is not quite as readily available as a non-contrast head CT, um, that can be a barrier to diagnosis. So, when a stroke is suspected, it's always important for um pediatric hospitals, um, or adult hospitals who might see children to have a pre-established pathway that is different for imaging um for stroke in children compared to adults. As I mentioned, MRI MRA is preferred in children, but um it is not as widely available and in some cases may require sedation or anesthesia if a specific focus stroke protocol is not available. Um, for some children who are at higher risk for stroke, who have, for example, an underlying heart condition and have cardiac hardware, MRI might not be an option. Um, CTCTA is commonly used in adults and also may be used in children, but, um, sometimes providers are hesitant to use CTCTA in children because of the radiation exposure. So again, MRI MRA is the preferred pediatric stroke imaging when it is readily available. MRI MRA has a number of um Of advantages. Uh, it is most sensitive for acute ischemia and is more sensitive than um CT. Diffusion restriction in MRI is positive within minutes and then remains bright over about a week, and it is probably the best form of imaging to differentiate a stroke from other stroke mimics, which again are common in children. An MRA is often added on to look for large or medium vessel occlusion. And at many pediatric stroke centers, a short focused stroke protocol MRI can be done. Um, oftentimes, one of the barriers for MRI without this protocol is that MRI can take a long time, up to 45 minutes or an hour. And often require sedation. With a focused stroke protocol, we can get the most important imaging within the first few minutes, um, and often can be done even in young unsedated children. CT, CTA and CT perfusion is probably one of the modalities that is most common in adults and is also possible in children. Um, this is the preferred modality at UCSF if there is a history of underlying cardiac disease, um, because then we're avoiding delays while we're trying to find out whether or not there's any cardiac hardware, uh, that might make MRI not possible. A non-contrast head CT is insensitive for early ischemia, um, but it is sensitive for hemorrhage. A CTA that's added on can look for large or medium vessel occlusion, and then CT perfusion will show uh ischemia and can parse it out between the core stroke, um, or the core lesion here shown in pink, and the surrounding tissue at risk. So, um, the core lesion is an area where we think that the stroke has already been completed and the tissue at risk, which is typically larger, especially early on after a stroke, is the tissue that is potentially available that can be salvaged by reperfusion therapy. So back to our case, our 114 year old boy. Um, So here again is his imaging showing the left MCA infarct and a cutoff of the distal middle cerebral artery. There's no hemorrhage. Um, labs showed that his, um, platelets were 122, his INR was normal. Um, he had no hypertension, and he was treated with thrombolysis with IV uh TPA at 4 hours and 9 minutes after he was last seen normal. He was not an embolectomy candidate because there's no large vessel occlusion. And I'll talk a little bit about um embolectomy or uh intravascular thrombectomy in our next case. So, I wanted to take a step back when we think about hyper acute stroke therapy, um, to acknowledge that all of our management strategies for hyper acute stroke treatment in children stems from the large number of trials that show benefit for these therapies in adults. So, um, for those who might not be familiar or need a reminder, um, the mainstay to uh hyper acute stroke treatment in adults is really to reopen the vessel, um, if there is a clot, and that can be done in a couple of different ways. Um. Intravenous thrombolysis performed within the 1st 4.5 hours of stroke with alta place, um, uh, has shown for many decades to improve clinical outcomes at 3 months. Um, IV thrombolysis can now be done with a couple of different agents, um, and tinect to place is now at use at most adult stroke centers. Um, connective place is just starting to be studied or to be looked at, um, with data in childhood stroke. In adults, endovascular clot removal. Or also called embolectomy, um, or thrombectomy can be done up to 24 hours. So this really extends the window of time in which we can treat a hyper acute stroke, um, and really still achieve benefit. So endovascular clo clot removal has been shown to be beneficial up to 6 hours in um anyone who has a large vessel occlusion, and it's been studied up to 24 hours um to show benefit in selected patients, and there have been a large number of clinical trials, some of which I have listed here. One of the concepts across all of these trials is that better outcomes are achieved with earlier treatment. So, conceptually, um, one of the reasons that um reperfusion therapy um works is because this concept that brain tissue injury increases over hours. So if we think of a stroke as having an area with an ischemic core, That it quickly dies and isn't salvageable, and it's surrounded by a number of tissue that has marginal blood flow. And that tissue may be able to survive for a period of time, but as time goes on and on, um, much of this tissue also um will die and can't be salvaged. So the goal of early uh hyper acute treatment is either IV thrombolysis or mechanical removal of the clot in order to reopen the vessel and allow blood flow to return to the ischemic penumbra. And down here below, I have an illustration of a um mechanical um removal of the clot with a catheter, which is extended up into an artery in the brain. From that catheter, there is a stent that is deployed into the clot itself. That is then um that stent grabs onto the clot and then is retracted in order to remove the clot and then um re-achieve blood flow. So, case number 2 is gonna be an illustration of um that mechanical embolectomy um in a child. So, this case is a 12 year old girl um who presented to her pediatrician with loss of hand sensation for one day. Um, the parent had called in asking for an urgent appointment. The appointment was via telehealth, and so there was no in-person physical exam, but the 12 year old was able to um explain exactly what happened. Um, actually, it was something that she had noticed when she was texting um her friend on the night before. And what she said there was no tingling, it was just a complete loss of sensation to her hand. She was still able to move it. There was no weakness, there's no trauma, no swelling, um, and really no other symptoms. When she showed on screen where it affected her hand, um, she noted that the pediatrician noted that it didn't fit any specific dermatome, and she planned to bring her into the office, um. And uh on exam. The strength was intact, and then she was referred to pediatric neurology. Before she could actually come in for her neurology appointment the following day, she had sudden onset of um face, arm, and leg weakness. Her father called 911. Last seen normal was about 1:34 p.m. and that's important because uh the last seen at normal time is the time that we use to measure the window for uh eligibility for either IV thrombolysis or thrombectomy. There was a family history of hypercoagulability in the family. Um, there was non elevated lipoprotein A and prothrombin 2010A mutation. These were her vitals on arrival to the ED, um, notably her, she was not um too hypertensive. Her blood pressure was uh cystolic 122. She was oriented, um, and she was alert, but had left-sided facial weakness. She had some dysarthy with speaking, and a little bit of drooling. She was able to move her left arm and move her left, uh, she was unable to move her left arm, but was able to move her left leg against gravity, but um it would drift to the bed immediately. Her NIH stroke scale at that time was 9, and a pediatric code stroke was called. So, what do I mean by a pediatric code stroke, and when should a code stroke be activated in a child? Um, when I talk to our trainees, I always emphasize that a code stroke should be activated for any new onset focal neurologic deficit that's unexplained when it's presenting within 24 hours, because it is possible that that person or the child might be eligible for hyper acute uh hyper acute stroke treatment within the 1st 24 hours. With inpatients, um, I also suggest a sudden onset coma without explanation, um, or a high-risk patient, for example, a child with a known cardiac disease who is postoperative or post-catheterization, who is not recovering from anesthesia as expected. When you are not sure, I always emphasize it's important to err on the side of calling. Who can activate it? Um, anyone can activate a code stroke. Anyone in the hospital, um, anyone who recognizes the signs and symptoms should call 911 and bring the child to the nearest emergency room for stabilization. For ED or inpatient providers, uh, please call the UCSF Access Center and you can ask to activate a code stroke. Aside from hyper acute management, early diagnosis is also the key to management of complications and secondary stroke prevention in the days after an ischemic stroke. So the infarct can expand, there could be hemorrhagic transformation, and there is an elevated recurrent stroke risk very early after stroke. Each of these potential complications can be minimized when we make the diagnosis early. In addition, acute symptomatic seizures are common within the 1st 7 days, and um elevated intrac cranial pressure increases for the 1st 3 to 5 days after a stroke. Sometimes this can actually lead to a malignant stroke syndrome, causing massive swelling and strokes in other territories when blood vessels are cut off, leading, leading to other parts of the brain. OK, coming back to our case two, The pediatric code stroke was called. This was at an outside hospital. So the local ED had reached out to their um their neurologist, and both of these were connected with the UCSF stroke team through our access center. With discussion, they decided to do a CT, CTA and CT perfusion, which was available faster than MRI, and that showed an occlusion of the right middle cerebral artery with a small core and a large surrounding penumbra, um showing that there was uh a large area of tissue at risk. She was given um IV altaplace at 4 hours and 12 minutes after stroke onset, so IV thrombolysis, and was transferred to UCSF for um consideration for possible embolectomy. She was taken by helicopter, um, landing on the helipad and then going directly to the OR. At the time that she arrived in the OR, her NIH stroke scale was still 9. They accessed her right femoral artery by 5 hours after her stroke onset, um, and showed that she did have a large vessel occlusion here in the middle cerebral artery. So in this illustration, we can see contrast in the right um ICA coming up here, and here we can see the vessel cut off with no flow um past this point in the middle cerebral artery. There are two passes with a stent retriever and then had full perfusion. You're again showing that same blood vessel now with perfusion um past the point of the prior clot. You can also see this on a lateral view with an area here um that was now fully reperfused after the clot retrieval. So we talked about recantalization therapy as being a mainstay of early um stroke treatment in adults, but what about in children? And so, it's important to mention that currently um uh IV thrombolytic agents are not FDA approved for children, um, and are considered either investigational or comp compassionate use. So, while thrombolysis and mechanical embolectomy are not yet considered standard of care in children, the evidence is quickly growing that there is likely to be benefit in children, and I'll talk a little bit about that in a moment. The reasons that we are, um, that they are still not um FDA approved is that uh there have not been large scale studies, particularly of thrombolysis. There was a clinical trial called TIPS, um, to look at thrombolysis in children, uh, that didn't accrue quickly enough and um was closed, but One of the major benefits of the TIPS trial is that it helped establish a large network of pediatric stroke centers that were um able to rapidly diagnose and treat children uh with hyper acute treatments um when they present with stroke. So, since 2015, guidelines, including the American Heart Association guidelines, um, European guidelines, and Australian guidelines have all increasingly recognized that thrombolysis and endovascular treatment is potentially reasonable. Um, AHA guidelines have suggested that it's reasonable in selected patients for thrombectomy to be considered when they present with a large vessocclusion, um. Under 18 years. And for um as evidence is mounted, many children's hospitals are implementing guidelines for when they would uh consider hyper acute stroke treatment. So I don't have time to go through all of the studies, but I did want to highlight one of the most important studies that has been done looking at mechanical embolectomy in children. The Save Child study was a retrospective multi-center cohort that looked at 73 children from stroke centers across Europe and the United States who underwent undervascular recantalization, and a couple of them were also 16 were treated with thrombolysis as well. They're about 11 years old, and they showed that the safety profile of thrombolysis was similar to adults, um, and in fact there were um favorable neurologic outcomes. So in this case, this shows the pediatric stroke scale of the 73 children um at admission. Then again at 12 to 24 hours um after treatment with their uh mechanical thrombectomy, and again at 7 days. In the lower graph, um, we can show a number of the adult studies in comparison the same child study for children with um similar pediatric stroke score, similar severity stroke at admission, and then effect at 24 hours and at 7 days, showing that there are similar effects after mechanical embolectomy in children um as there are in the uh prior adult studies. Since that time, um, to address the limitations of that retrospective study, there has been a prospective registry to look at, um, children who have large or medium vessel inclusion who are treated with endovascular thrombectomy. So this is the Save Child's pro study that was an analysis of about 208 children um at 45 centers in 12 countries. And there are a couple of major takeaways from um this study. They compared um uh children with endovascular thrombectomy to those who received best medical treatment. And best medical treatment could include thrombolysis. So there were children who had thrombolysis in both groups. On the whole, the groups on admission were different with the children who were treated with endovascular thrombectomy actually having more severe stroke um at the time of their admission, with PH stroke scale of 14 compared to 9 in the best medical treatment arm. And despite the more severe stroke on admission, endovascular treatment was associated with better functional outcomes. Now there are still some limitations to this study, but um overall, um, especially since the recent, this recent publication, um, there, there are many other um pediatric stroke centers who are, um, addressing hyper acute stroke treatment with uh endovascular thrombectomy for children. So what are the major barriers for pediatric stroke treatment? One of the big ones is lack of public and provider awareness. So both parents, caregivers and providers are oftentimes not aware that stroke occurs in children. Um, or that there's hyper acute stroke treatment that's available. This includes, um, adult ED providers, which is one of the largest places in the US where children actually present for their stroke, um, more commonly at adult hospitals than at children's hospitals. Because of these barriers, um, one of my major drives is a call for pediatric stroke readiness at all levels of our medical system, um, and in the public. If we can help to um have a larger scale understanding that children can present with stroke, um, we can improve the speed in which we both um have them present to medical care and diagnose and provide hyper acute stroke treatment. So I only have a few minutes left, but wanted to just um illustrate some recent data from a survey um from the American Heart Association Western states of 75 Northern California hospitals. These were primarily not children's hospitals, but short-term acute care hospitals, some with critical care access, and also included one veterans hospital. And what we know from this survey is that pediatric pediatric stroke readiness was low at most Northern California hospitals. Um, so most of the hospital reported that there was no frontline staff and provider training in pediatric stroke, and um the majority didn't have an established pediatric stroke alert or stroke code system for children, although a number of those um had uh a system in development. Most of them did not have an institutional pediatric stroke team available which for consultation, which may not be much of a surprise because these were primarily not children's hospitals, um, but, um, we also didn't have, um, I don't show these data, but they didn't have a ready referral with a protocol transfer with a regional hospital, um, or institutional system for outpatient follow-up for a child who had a stroke. And while these primarily um these are data from Northern California, we know as we look across the United States and across the world, that there are large geographic disparities um and um low stroke readiness across the United States and in the world. So what can we do to improve the access to hyper acute stroke therapy for children? The first main one is to help pediatric stroke centers be ready for early intervention. So what that means at UCSF is that we have created guidelines for hyper acute stroke treatment that helps us to make um quick decisions about who may or may not be eligible for thrombolysis or thrombectomy. We have a multidisciplinary stroke ready team that includes our PIU providers, our neurohospitalists, and neurosurgeons, as well as endovascular surgeons to provide um thrombectomy in the right situation. We have systems for treatment, including imaging protocols and nursing protocols. And um, What when I speak to people in other regions, I emphasize that one of the important things is really to understand what the regional needs are, who are the patients at risk in your hospital and in your area. So recognizing that we can improve awareness, for example, in um cardiology clinics, in hematology clinics where children with sickle cell disease are treated, um, knowing whether or not your your Institution needs a uya moya program where vascular malformation program can be ways of addressing your regional needs. And finally, I often refer people to the International Pediatric Stroke Organization. Um, which provides clinical guidelines, education, advocacy, um, and has patients specific resources. Um, this is a great resource for any provider. Um, we welcome members, um, the membership includes lots of education about pediatric stroke through regular webinars, um, and, uh, challenging case series. So what we want to move is um from a picture like this with um jumbled thoughts about what to do when a child presents with a stroke. To a place where there is a stroke plan. For anyone who's interested, we do have and can provide a referring provider workflow like this that can be posted on the wall of your office or in an emergency room that reminds people to consider when stroke might be on the differential, also provides um numbers for quick referrals, and a checklist of what to do while awaiting for transfer in order to stabilize a child. Um, things to do in terms of minimizing delay and names of the people on our team. So, just to wrap up, and I, I know we're a little short on time, but I want, if there is one major takeaway from today's webinar, is I want to emphasize that please remember that children can have strokes. It's important to recognize those signs and symptoms of stroke in children in order to avoid delays in treatment. Getting them to rapid diagnostic imaging is critical to then bringing them to um hyper acute therapy. And thanks so much. Um, I'm happy to stay and take some questions and answers.
