Delay in Diagnosis of Basilar Artery Stroke.

BACKGROUND: Basilar artery stroke causes substantial morbidity and mortality. Although its unusual clinical presentation potentially contributes to a delay in diagnosis, this problem has not been systematically studied. We compared intervals between symptom onset, initial presentation, and diagnosis in stroke due to basilar artery (BA) versus left middle cerebral artery (LMCA) occlusion to determine the presence of and potential reasons for diagnostic delay in BA stroke. METHODS: We retrospectively identified 21 consecutive adult patients diagnosed with BA stroke between 2009 and 2011 from our hospital's prospective stroke registry. Patients were age-, sex-, and race-matched with 21 LMCA stroke patients from the same period. All subjects had confirmed clinical and radiographic diagnosis of stroke due to occlusion or stenosis of the BA, LMCA, or left internal carotid artery. Time to diagnosis was determined independently by two investigators through medical record review. The pre-specified primary outcome was latency from emergency department (ED) arrival to stroke diagnosis. RESULTS: Median time from ED arrival to diagnosis was 8 h 24 min (IQR: 2:43-26:32) for BA and 1 h 23 min (IQR: 0:41-1:45; p < 0.001) for LMCA. Median time from symptom onset to ED arrival was 7 h 44 min (IQR 1:23-21:30) for BA and 1 h 2 min (IQR 0:36-9:41; p = 0.06) for LMCA. Four of 21 (19 %) BA patients were diagnosed within a 4-h time frame to make intravenous thrombolysis possible compared to 13 of 21 (62 %) LMCA patients (p = 0.01). CONCLUSIONS: Our results suggest that both pre-hospital and in-hospital processes cause substantial, clinically significant delays in the diagnosis of BA stroke.

Special considerations in infants and children.

Head injury in children is one of the most common causes of death and disability in the US and, increasingly, worldwide. This chapter reviews the causes, patterns, pathophysiology, and treatment of head injury in children across the age spectrum, and compares pediatric head injury to that in adults. Classification of head injury in children can be organized according to severity, pathoanatomic type, or mechanism. Response to injury and repair mechanisms appear to vary at different ages, and these may influence optimal treatment; however, much work is still needed before investigation leads to clearly effective clinical interventions. This is true both for the more severe injuries as well as those at the milder end of the injury spectrum, the latter of which have received increasing attention. In this chapter, neuroassessment tools for each age, newer imaging modalities including magnetic resonance imaging (MRI), and specific pediatric management issues, including intracranial pressure (ICP) monitoring and seizure prophylaxis, are reviewed. Finally, specific head injury patterns and functional outcomes relevant to pediatric patients are discussed. While head injury is common, the number of head-injured children is significantly smaller than the corresponding adult head-injured population. When divided further by specific ages, injury types, and other sources of heterogeneity, properly powered clinical research is likely to require large data sets that will allow for stratification across variables, including age. While much has been learned in the past several decades, further study will be required to determine the best management practices for optimizing recovery in individual pediatric patients. This approach is likely to depend on collaborative international head injury databases that will allow researchers to better understand the nuanced evolution of different types of head injury in patients at each age, and the pathophysiologic, treatment-related, and genetic factors that influence recovery.