Suspected Stroke Clinical Pathway — Emergency Department

Initial Treatment Guidelines

Continue neuroprotective interventions:

Hyperacute Therapy	Consider if eligible for tPA or thrombectomy Children presenting within 4.5 hrs of last witnessed to be well (without deficits) might be eligible for tPA Children presenting within 24 hrs of last witnessed to be well (without deficits) may be eligible for thrombectomy Call Stroke Team to mobilize hyperacute imaging and treatment
Antithrombotic Treatment	Children with suspected acute ischemic stroke with CT negative for an acute hemorrhage should be given an initial dose of aspirin Systemic anticoagulation is reserved for selected diagnoses with discussion with Stroke Team Arterial dissection Cardiogenic embolic stroke Venous thrombosis
Anti-Seizure Medication	Treat acute symptomatic seizure occurring at or around stroke symptom onset Status Epilepticus Pathway If history of seizure, review anti-seizure medication with Stroke Team
Initial/Admission Lab and Risk Factor Screening Studies	Assure the following have been obtained: CBC, platelet count PT, PTT, INR BMP EKG Other labs (e.g., thrombophilia or vasculitis workup) should be discussed with Stroke Attending and admitting service
Special Cases	STAT consult to hematology for children with sickle cell anemia to discuss: Imaging recommendations Need for exchange transfusion Need for simple transfusion Thrombolysis is not usually used in patients with sickle cell anemia or Moyamoya disease

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.