Early stroke detection in children after cardiac catheterization

Children with congenital and acquired heart disease are at increased risk for stroke with 15-37% of strokes occurring in the peri-procedure period.  Stroke can be difficult to identify in children resulting in a high rate of morbidity and mortality; however, children can be treated successfully with hyperacute therapies (i.e., tissue plasminogen activator or thrombectomy) if identified promptly. Thus, we developed and implemented a screening tool to decrease the time to detection of stroke in children after cardiac catheterization.

Retrospective analysis of the medical records at Boston Children’s Hospital between December 2006-July 2016 identified children who had a stroke after cardiac catheterization.  Characterization of the presenting symptoms guided the development of a standardized screening stroke assessment. The assessment was incorporated into the electronic medical record and the cardiology bedside nurses were trained in its use.  The performance of the screen was analyzed retrospectively in the previously identified cohort and is now being applied prospectively to all post-catheterization patients to validate the specificity of the screen.  

Twenty children had a clinically-apparent stroke following cardiac catheterization prior to the implementation of the screen. The majority of the children presented with signs of stroke within 48-72hours following cardiac catheterization; however, the median time to imaging that identified the stroke was 18hours, well outside the window for intervention.  Retrospective application of the screen detected 18/20 (90%) strokes in children following cardiac catheterization.  

Although stroke in the post-catheterization period is rare, it poses a significant morbidity and mortality risk. The majority of clinically-apparent strokes in our cohort occurred within the peri-procedural period, suggesting that this represents a pivotal period for heightened awareness of stroke symptoms.  Development of screening tools to rapidly detect stroke in children is imperative to the provision of hyperacute therapies, thereby decreasing morbidity and mortality.