Abstract 40: The Impact of an Institutional Acute Stroke Protocol on Time to Treatment of Childhood Stroke

Introduction: In pediatric stroke, reported median delays from symptom onset to imaging diagnosis are 16-24hrs. This results in delayed treatment initiation. The impact of an Acute Stroke Protocol in pediatric hospitals has not been reported. Such a program was implemented at SickKids in 2005. The current study measured the impact of this protocol on delays to diagnosis and initiation of antithrombotic agents. Methods: We compared time to diagnosis and treatment in children (age 1mo-18yrs) with acute AIS diagnosed after stroke protocol implementation (‘post-protocol’ from 2005-2012), to 209 children diagnosed ‘pre-protocol’ 1992-2004. Focused health record reviews abstracted intervals from symptom onset to diagnosis and to initiation of first antithrombotic treatment. We statistically compared time intervals in pre and post-protocol cohorts. Results: Among 118 children diagnosed post-protocol (75 outpatient and 43 inpatient strokes), median age was 5.8 years with 65 males. Median delay from symptom onset to diagnosis in post-protocol children was similar to pre-protocol children, for all strokes (19.9hrs vs 22.7hrs respectively; p=0.24), outpatient (22.4hrs vs 29.1hrs; p=0.12) and inpatient strokes (12.8hrs vs 14.6hrs; p=0.92). The main contributors to diagnosis beyond 6 hrs were delays in initial neuroimaging (25% of delays) and false-negative neuroimaging results (19% of delays) in CT scan as first test. The interval from diagnosis to antithrombotic treatment was more frequently within 24 hours for children treated post-protocol (55.1% vs 18.7% pre-protocol;p<0.0001) and in post-protocol children this interval was median 4.5 hrs (IQR 1.9-16.6). Also children with inpatient strokes more frequently received antithrombotic agents post-protocol (58% vs 35% pre-protocol;p=0.031). The types of antithrombotic treatments were similar (p=0.337). Conclusions: The implementation of an Acute Stroke Protocol in our children’s hospital reduced the time to initiation of antithrombotic treatment. As thrombolysis and other hyper-acute treatments become available, the implementation of institutional Acute Stroke Protocols in children’s hospitals will be an important strategy to increase access to these therapies for children with AIS.