Time to diagnosis was determined in 41 children, 0 to 18 years, with ischemic or hemorrhagic stroke documented prospectively or by retrospective chart review of the last 2 years database, at State University of New York, Stony Brook, NY. Twelve neonates diagnosed in the neonatal period were excluded from analysis. Of the remaining 29 (mean age at presentation 8.67 years), 24 had accurate time records, and 28 events were recorded. Ischemic stroke occurred in 21 events and hemorrhagic stroke in 7. The cause was idiopathic in 18 (46%) and embolic in 4 (surgery and atrial myxoma); vascular malformation was present in 3, arterial dissection in 2, inherited coagulopathy in 3, and moyamoya or other syndrome in 4. An underlying known disorder was found in 38%, and a predisposing disorder in an additional 15%. Initial symptoms were headache in 32%, motor in 60%, sensory in 7%, aphasia in 14%, seizures in 10%, and mental status change in 21%. Time from clinical onset to first medical exam was an average of 28.5 hours, and time to diagnosis of stroke averaged 35.7 hours. Unless hemorrhagic, stroke in children is rarely diagnosed in <3 to 6 hours from onset, a major criterion for inclusion in therapeutic trials of thrombolytic or neuroprotective agents. [1]

COMMENT. Stroke with massive hemorrhage demands immediate medical attention. Ischemic stroke is less dramatic and medical attention is delayed. Compared to the 35 hour delay in children, stroke in adults is treated as an emergency and the total delay time, symptom onset until CT completion, is only 4 hours (range 2.3-8.3 hours) (Morris DL et al. 2000). Reasons for excessive diagnostic delay in children include their inability to describe symptoms such as headache, sensory or cerebellar symptoms, and difficulty in recognition of some neurologic signs, eg aphasia. Increased awareness of predisposing causes (eg cardiac, sickle cell disease) should lead to earlier diagnosis and treatment.

Risks of posterior circulation stroke are evaluated in 22 cases (17 boys) identified in a retrospective study at University College and Great Ormond Street Hospitals, London, UK. [2]. Vertebrobasilar arterial abnormalities (vertebral artery dissection in 10) were present in 20, multifocal in 12. Cardiac abnormalities with embolism were present in only 4, hypertension in 9, and factor V Leiden and other gene mutations in 6. Two had subluxation of the upper cervical spine. During follow-up for 6 months to 11 years, 5 (20%) had recurrence and 7 had TIA; 12 (50%) had no residual deficits. Investigations include MRI, cerebral angiography, echocardiography, and cervical radiography. In contrast to anterior circulation stroke, where 50% have a preexisting disorder, the majority with posterior circulation stroke are previously healthy.