Hi Ben -
While I think it is always useful to commit to intensive and careful review
of clinical experience, recruitment and organization of resources and
approaching complex problems systemically, I remain skeptical of the value
of a 'stroke team' approach to pediatric stroke, with the exception perhaps
for kids already diagnosed with high risk conditions such as sickle cell or
Fabry's or hypercoagulation states.
I feel when you start having this level of resource commitment to an
uncommon event, the inevitable result of such diagnostic and therapeutic
momentum is an overuse of resources and over-treatment (which in this
disorder could be deleterious to the patient).
I feel this way based upon our department's experience (and my review of
the literature, albeit biased). Our department is only 30 k visits annually
but I am aware of nearly all of the stroke cases at our place in the last
25 years and this is what I have seen:
1) Stroke mimics and conversion disorders mimicking stroke symptoms are at
least one and maybe two orders of magnitude more common than true ischemic
strokes in kids. With ratios like this children without ischemic stroke are
undoubtedly going to be misdiagnosed and perhaps harmed by an algorithmic
approach, in my view.
2) Hemorrhagic strokes present early and ischemic strokes present late or
at least rarely present early in kids (within, for example, a three hour
window from symptom onset).
3) Ischemic stroke amenable to medical or interventional therapy is quite
rare -probably on the order of 0.1 to 0.05x less frequent than the already
infrequent occurrence of septic shock.
The point is, study the topic as an institution and run an efficient and
organized facility with good clinicians and I think you will be fine. I
think speed and urgency, created by 'swat team' like approaches to complex
problems, could be counter-productive.
And beware of overtreating children - check out..
Cunningham AS. Beware of overtreating children. AJDC 1989.
Jay Fisher MD FAAP FACEP
Medical Director, Pediatric Emergency Services
Children's Hospital of Nevada at UMC
Clinical Professor of Pediatrics and Emergency Medicine
UNLV School of Medicine
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