Unique Approach to Stroke Care
Dr. Torres and Dr. Acosta, co-directors, Cook Children’s Pediatric Stroke and Thrombosis Program, take us on a deep dive into the causes of pediatric stroke and how their unique B.E.F.A.S.T. approach is improving awareness, diagnosis, treatment and risk of recurrence. It’s a life changing journey for provider, families and especially for children.
Meet the speakers
Host: Today, we're talking with Dr. Marcella Torres and Dr. Fernando Acosta, co-medical directors of the Cook Children’s Stroke and Thrombosis Program. Before we get started just a little background on our guests. Dr. Torres is also the medical director of the hematology program at Cook Children’s. And Dr. Acosta is the associate medical director for movement disorders at the Jane and John Justin Neurosciences Center here at Cook Children's. Dr. Torres earned her medical degree from universidad Peruana Cayetano in Lima, Peru, and completed her fellowship at Children's Hospital of Wisconsin. She is board certified in pediatrics and pediatric hematology oncology. Dr. Torres is an active member of several hematology and stroke related organizations. She is also actively involved in research and has written for numerous peer reviewed publications. Dr. Acosta earned his medical degree from the university of Texas Health Science Center in San Antonio. And he completed fellowships in pediatric neurology, neurophysiology and movement disorders at the University of Texas Health Science Center in Houston. Dr. Acosta has written extensively on deep brain stimulation has presented around the globe and his work has appeared in many peer reviewed publications as well. Welcome to you both.
Dr. Acosta and Dr. Torres Thank you.
Host: So the Stroke and Thrombosis Orogram at Cook Children’s is a little unique in that it is led by both hematology and neurology. Can you talk a little about the program and especially why it makes sense to combine both disciplines?
Dr. Torres: Well, the causes of pediatric stroke are quite different from adults and children and in children, many of the causes for pediatric stroke will have an indication for anticoagulation therapy. Now, anticoagulation is done by a hematologist, which is the reason why the combination of both hematology and neurology in the management of pediatric stroke is, uh, important. It's approximately two thirds of children who have pediatric stroke will need anticoagulation management and also anti-platelet therapy. So teaming up with Fernando has been the best decision we both made when we are trying to take care of these children.
Dr. Acosta: To echo that sentiment, here at Cook children's with having a neurologist and the hematologist tightly involved in the stroke program. We have more services running the program than most of the pediatric stroke programs across the country. Many of the programs across the country are envious that we have a hematologist that's so tightly linked to the program, and she adds so much to managing these patients. And we're lucky to have this kind of collaboration in Cook Children’s. In addition to the two of us, we have certain colleagues that we call on for strokes in cardiology, rheumatology, neurosurgery, and other services that may be needed depending on the complexity of the stroke case that we're involved in. And through that collaboration, we are able to make sure that we have covered every aspect of that child's care, and to provide the best above standard of care treatment in a stroke patient, in a child that's available in this day and age.
Host: With so many possible causes of stroke, what tools are available to determine the causes of stroke in a child, once you determine a cause, are there tools to help reduce the risk of recurrence?
Dr. Acosta: So the tools that are available to determine the cause or tools that we use in the acute phase of a child with a stroke, or even the first initial encounter with a child that's had a stroke in the past, and those tools reside in radiology and at Cook Children's, Dr. Torres and I have asked for increased technology in our radiology machines and services, and they've always accommodated that. And we have some cutting edge technology that we use in managing these patients and trying to figure out the cause of a stroke in a child. Oftentimes the cause of a stroke in a child can evade us and can be difficult to find. But we have many tools that are at our disposal. Initially, it's a lot of MRI studies that give us location of the stroke and can give us other characteristics of the stroke that lead us to consider certain causes of that stroke in that child.
And then following that, there may be followup studies that we need to do. And again, in the radiology area of doing conventional angiograms, uh, which is not routinely done in kids, we also have other, um, proprietary software looking to upgrade and continually upgrade our radiology services to meet the needs of these kids with strokes of a very complex disease that can have a very impactful outcome that lasts for many, many years in these kids. Once we're able to determine a cause, then we can start looking at what we need to do to either stop the process or curtail the process. Cause in some cases we can't completely stop the process, but we can manage it, slow the progression of it down, limit the amount of disease and destruction that happens from stroke and improve outcomes and improve the quality of lives of these kids. And so some of those tools are looking at anticoagulation studies. Some of the tools are the rehab studies that we do and including cutting-edge rehab techniques, we're starting a robotics program here at Cook's. And that was very exciting for our stroke population. So these are the things that we have available at Cook Children’s to evaluate and continue to manage these kids that suffer stroke.
Dr. Torres: I did want to add that besides all the radiology support that we count on, there's also many blood tests that we do in, um, the children who suffer an acute stroke, trying to find conditions that what I call tell the parents that thicken your blood and may have predisposed a child to develop a blood clot. Now, almost one third of the pediatric strokes are related to congenital heart disease or acquired heart disease. So again, we rely on our cardiology colleagues and echocardiograms. The older third of patients also suffer from blood disorders. For example, sickle cell disease also managed by a hematologist and finally many of them will have vascular diseases that are actually genetic in origin. So we count, uh, with colleague in the genetics department, in our genetics department that, um, has a special interest in a cerebral vasculopathies and has been extremely helpful to find the reason why a child has a very abnormal blood vessels, for example, and guide us in the management of these children using anti-platelet therapy or anticoagulation and blood pressure medications, antiplatelet therapy or immunosuppressive drugs, trying to stop the progression of this vascular disorders.
Host: Dr. Acosta, in a recent article you noted that children's strokes are often misdiagnosed as a migraine or viral illness. You also talk about stroke mimics. What does that mean? What can healthcare providers do to improve diagnosis?
Dr. Acosta: So my mentor in pediatric neurology had a saying that uncommon things present, commonly, meaning that a common symptom can usually mean it's just a mild cold or an illness, but it could also mean that you have severe neurologic disease or some other disease. And so in pediatrics, there are conditions where it may be confusing if it's a stroke or if it can be another diagnosis such as migraine headache. It is commonly seen that migraine headaches can cause focal neurologic symptoms. However, if that child is having a first time migraine headache with first-time focal neurologic symptoms, stroke should be considered very high in that differential diagnosis. It should be excluded. And then think of other possibilities. The reason that we want stroke to be thought of more is because time is important and the earlier you intervene, the more you can reduce the long-term outcomes and morbidity that happened from stroke, the way that healthcare providers can improve their pickup of stroke diagnosis is to have it on their brains, have it in their minds, many providers that deal with kids don't think of stroke very much as a possibility.
Dr. Torres and I go out on the lecture circuit all the time and we'll have community pediatricians when they see what our topic is say, “Kids have strokes?” And usually our first slide is kids have strokes in big bold letters because we want to raise the awareness, not only in the community, but also our healthcare providers that see these kids for them to think about stroke. Because the sooner you can diagnose the sooner you can intervene and the much bigger difference you can make in the life of that child has many, many more years to live with the consequences of a stroke.
Host: So many people are surprised to learn that stroke can occur before a child is even born? How common are perinatal strokes and are there maternal risk factors that can increase the risk of perinatal stroke?
Dr. Torres: So actually in pediatrics, the two groups that have a higher incidence of acute or arterial ischemic strokes, I should say, are the neonates up to less than one year of age and teenagers, um, starting at approximately 15 years of age and going up. So it keeps going up as they age. So those two groups are your highest incidents of arterial schemic stroke. And unfortunately, perinatal stroke doesn't have a definition approved across the board in the pediatric medical community. Some people define it, you know, a week before birth and a week after birth. The majority though approved that definition of a stroke that happens gestational age of 20 weeks and above that majority of the pediatric neurologists though approved that definition of stroke that happens at 28 weeks of pregnancy and extending up to 28 days after birth.
There's not a cause and effect type of mechanism, but we do know of many maternal risk factors that can increase the odds of a neonate having stroke. For example, maternal hypertension, obviously maternal preeclampsia or eclampsia or legal hydrometers, which is decreased fluid in the amniotic SAC, or for example, placenta previa, which are complications of placenta at birth or during pregnancy. And of course, infection. Those are very big risk factors for the neonates. Now we do have to say that still a neonatal stroke is unusual, right? So not every woman that has placenta previa will have a child who suffers a stroke. So that's why it's not a cause and effect, but we do know that all of those can represent risk factors for a neonatal stroke. And of course, there's also conditions in a neonate, for example, genetic conditions that make the blood of the neonates thick and predispose him to clots, congenital heart disease infection, et cetera.
So again, there's many risk factors described that increase their risk of a perinatal stroke.
Host: If a baby's born and it's recognized that they had a perinatal stroke, how is that treated?
Dr. Torres: So unfortunately the management of perinatal stroke is more preventing the recurrence if the child has a high risk of recurrence. So the first thing for us is why does this happen? So we look for all the causes I just mentioned and see if we can identify why the neonate had a perinatal stroke. And then the second step is to decide, do we need to give them a blood thinner or an anti-platelet therapy or anything to prevent a recurrent stroke? The majority of cases, we do not need to give any medication to prevent a recurrence stroke because most of the time, unfortunately it's related to the birthing process and to maternal conditions and not necessarily the baby, the exceptions are babies with congenital heart disease. Most of those patients, we will follow for the rest of their lifetime.
Dr. Acosta: So to add to Dr. Torres’s comments on the management of a perinatal stroke, most of it is supportive care. Once we figure out the reason for the stroke and also recovered rehabilitation. And so it is a neonate, a baby, and we get our therapists working with them right away, stretching, getting them, moving, doing the therapies that will help improve the outcome of what that stroke has caused. What it does is it's engaging that child's brain to develop other pathways because their brain is more plastic than an adult brain, and plasticity when we're talking about brains means the ability of neurons to grow new connections that they otherwise wouldn't have grown to overcome the deficits that a stroke or other brain injury would cause. And so the sooner that you start that the better the outcome will be. And again, we have a very active rehabilitation program at Cook Children’s that ties in very nicely with our stroke program,
Host: The most popular known term for recognizing the warning signs of stroke comes from the National Stroke Association, called FAST. But BE FAST is being used more in pediatrics. Can you talk about what that means and why it's critical in pediatric care?
Dr. Acosta: BE FAST is a mnemonic that we employ in pediatric stroke. B stands for balance problems. It may be the child is limping. All of a sudden without injury, the child is unbalanced. The child is wobbly. Uh, those are things to look for, ease for eyes. They may have eye movement abnormalities. They may have trouble looking at one side or moving their eyes in a certain way, or their eyes may not be together. And they may look cross-eyed. And those are things to watch for F is for face. And it would be for asymmetry of the face. One side of the face looks very different from the other side of the face. Sometimes people say, it looks as if one side of the face is almost sliding off compared to the other side A is for arm or leg. And so you're looking for armor leg symptoms. That can be weakness, but in kids that can also be abnormalities of movement.
So from their normal easy movement to grab an object, they may have a weird pattern of movement that they're grabbing an object in an odd way that they've never done before. And that may be a symptom of a stroke. S is for speech and commonly in kids, their speech is more effected in stroke than we see in adults. And that can be from them, slurring their speech to becoming mute to saying words that are jibberish or not understandable. And that would be a significant sign that there's a possible stroke. And then T stands for time to call nine one one. And we talk about the urgency and stroke is to get them to medical care, to get intervention started quicker. And so that's a very important aspect is to call nine 11 as quickly as you recognize one of these symptoms. The reason we add balance and eyes is just to increase the yield and pickup of a kid that may be having a stroke because they may have those abnormalities that can also indicate stroke in a child. And we don't want to miss that opportunity to make a big difference in getting that child to acute medical care and a window where we have options available to treat that acute stroke and greatly reduce the consequences of that stroke and really make a difference in how that child will do going forward.
Host: When you talk about treatment and recovery, you often say time is brain. What do you mean by that?
Dr. Acosta: This goes back to the previous point that we want to get this child to acute medical care, to consider if they're appropriate for an acute intervention. The data shows that time is brain. So every minute you lose a million neurons that are dying, that are not getting enough blood or oxygen. And so when we can get them into an acute facility that can care for their stroke and we can reestablish blood flow, getting oxygen and nutrients to that part of the brain, you're going to save neurons. And every minute ahead of that, you can do it. You're saving a million neurons. And so that can mean a lot of difference between maybe somebody being able to walk and not being able to walk. And you're talking about many, many years of this child being functional. And that could be the difference between having functional use of an arm that they're able to use adaptive equipment and have a full life and maybe an independent life.
ereas if you let that stroke continue to expand, their outcome is going to be much worse. So that is why Dr. Torres and I go out and raise awareness. Cause we want these kids coming to medical attention, as quick as we can get them there. It's often in our experience that we see kids with devastating stroke that are outside the window to do anything. And then you're just doing recovery and trying to improve what they have and trying to make life as best you can. Whereas we miss that opportunity to make a big difference and then work from that point where they're much better able to do things functionally for themselves.
Host: In a recent presentation, you noted the cost of pediatric stroke care in a single year. It was approximately $42 million. Why is that? And can anything be done to reduce that cost?
Dr. Acosta: This data is actually from a few years back. So this cost is probably more in today's world, but that includes all aspects of stroke. And when you talk about this very acute presenting problem, that requires a lot of medical care and a lot of medical technology, there's a lot of costs upfront. They come into the ER, they will need an ICU admission. We need repeated imaging. So those tools are effectively used. And I think that's money well spent included in this cost is post stroke care. And the worse outcome, you have, the more medical services that patient's going to need. They may need skilled nursing. They may even need to be in a facility because their needs are so high they can't live at home or their parents are unable to care for them at home. They may need lots of therapy. They may needs lots of equipment.
And so if we can reduce the severity and morbidity of these outcomes in these kids, by intervening earlier, you can save money on the backend of that and maybe be able to reduce the cost it takes to care for that child. And then you take that a step further. And if their functional outcome is good enough to where they can hold a job and get paid medical benefits and things like that, then it carries even further than that. Not to mention the improvement in that child's quality of life as they become an adult and can be more self-sufficient rather than relying on others for their care.
Host: Is there one critical aspect you would like to see changed in the diagnosis and treatment of pediatric strokes that could greatly enhance outcomes for pediatric patients?
Dr. Acosta: So I think in order to really look at this question, we should take a look at the experience in the adult stroke treatment. Years ago, somebody recognized the need that adult patients have lots of strokes, and we need to get better at treating them and recognize the need to get faster treating them. And so they developed all of these primary stroke centers that started doing research in adult stroke, started figuring out ways to intervene faster and with the improved treatment options, which developed into these acute stroke teams that they have now, and the acute stroke teams are on call 24, seven it's specialized care. They begin care in the field. The ambulance operators are talking to the neurologist back at the hospital and they're already prepared to receive them. And we call it time from door to drip. The drip is the clot-busting agent that many adults we'll receive to break the clot up and reestablish blood flow to that region of the brain.
And they have gotten these times down and gotten this care so streamlined than an adult with a stroke comes into a pathway. And it receives top-notch care by doing all this research and doing all these investigations and figuring out what works and what doesn't work and what makes the most effective use of your time. As far as that's concerned, in pediatric stroke, we're way behind the adult world in doing that. And that's why people such as myself and Marcella have wanted to do this because we need to get better at treating pediatric stroke. And as part of that, we're part of the International Pediatric Stroke Society that is a research society that's looking at trying to figure out the answers to these questions that we have in pediatric stroke. And in what ways can we become better, more streamlined with more effective treatments to have better outcomes in these kids. And so when you look at the adult model, the studies have shown that by improving that care in adults, the morbidity is reduced. The length of hospital stays reduced, the need for post stroke care and services is reduced. And so overall it has greatly improved the care of stroke in adults. And we want to get there with kids and we are on the forefront of that with our colleagues around the world in trying to improve pediatric stroke care.
Dr. Torres: And just to echo that, I think I would try to summarize that the need in pediatric stroke is research and early recognition of the stroke. So for early recognition, our colleagues that are doing similar work in the different states in the country are trying to increase community awareness and also increase awareness within the medical community actually. So that an early diagnosis on an early suspicion of a pediatric stroke happens. And then the second part is where do we send this kid that I think is having a stroke? So we would like to model the adult management and having determined centers that are specialized in pediatric stroke. They are called primary pediatric stroke centers. To be designated as one, there's still not an established rule from the American Heart Association or from Jayco, for example, but at the same time, this institutions have to have, for example, a 24 seven MRI capability or neuroradiologist in house have a stroke alert system,
and we're proud to say that here at Cook Children’s we have developed a stroke alert system that is around the clock and provides this specialized care for any patient that presents to our emergency department or for any patient from anywhere else that wants to contact our emergency department or intensive care unit and wants to refer a patient to us acutely. We count with an excellent transport system, as you all know. So we are really trying to move forward and early recognition, early treatment and our active participation in the different research projects right now, going on in the International Pediatric Stroke Society, I think is moving us in the right direction, but there's still a lot more needed, including funding, because this is not a very common disease in, um, children even this is one of the 10 most common causes of death within the pediatric age because pediatric strokes do not happen ...
... as often as adult stroke, funding for research is very sparse and difficult to obtain. To perform research that has meaningful results requires the participation of several institutions, which has prompted the creation of institutions that try to group all the pediatric stroke cases that happen not just within our nation, but also internationally, such as the International Pediatric Stroke Society. Funding though is still sparse and difficult to obtain. We are trying, for example, to obtain funds to find protocols where we can give this clot busting medication, not just within four and a half hours from the stroke event, but try to extend that time, which would highly benefit children. We are here at Cook Children's count with very specialized intervention radiologists that can thread a catheter into the arteries of the brain and give that clot busting medication or pull out the clot. But again, research is needed because we don't even count with small enough catheters to do that process. Once we get to the toddler age. So they don't even make small enough catheters. So again, research has to show entities and pharmaceutical companies that it is worthwhile investing in creating all this so that little children can also benefit from what adults currently have. So I think that's where increased awareness of this problem is needed.
Host: Dr. Torres and Acosta, thank you both so much for talking with us today to say for taking time out of your busy schedule would be an understatement. So we really do appreciate your being here today. Cook Children’s Stroke and Thrombosis Program is a proud member of the International Pediatric Stroke Society, a network of pediatric institutions that are world leaders in therapy and research in the field of pediatric stroke and thrombosis. If you'd like to learn more about the stroke and thrombosis program at Cook Children’s or scheduling a presentation on stroke and thrombosis with this amazing team, please visit our website at Cook Children’s dot org.