Scott Webb (Host): Welcome to UK HealthCast, the podcast from UK HealthCare. I'm Scott Webb and today, Dr. Kevin O'Connor, Vascular Neurologist who specializes in pediatric stroke, is joining us again and today he's going to share the essential info, including information about the algorithm that was developed to help Kentucky Neuroscience Institute providers who treat pediatric stroke patients.

Dr. O'Connor, it's great to have you back on. We're going to talk a little bit again about pediatric stroke today, but in a little bit sort of different lens than we did last time, but let's start here for listeners. What is pediatric stroke?

Kevin O'Connor, MD: Pediatric stroke is kind of what it sounds like from the adult side, where you have a stroke, except it's happening in a child. And when we think of a stroke, that's either too much blood getting to the brain, what we like to think of as a hemorrhagic stroke, or it's too little blood getting to a part of the brain. Those are the strokes that we call ischemic strokes.

And there's a lot of different things that can cause both the hemorrhagic strokes and the ischemic strokes. But when we think of those happening in a child, we're typically thinking of anyone that's about 30 days of life to about 18 years of age. And it sounds kind of silly, like why are you excluding everyone less than 30?

But we tend to do that for clinical reasons, because when you're 30 days of life and under, a lot of the things that can happen in terms of causing a stroke and treating a stroke are a lot different from simply being two months old to 18 years. So we like to break stroke up into that 30 day to 18 year range and then the much younger children we typically call those perinatal strokes.

Host: Okay, and why do you think it's important to you as an expert here? Why do you think it's important that we treat pediatric strokes just like adult strokes.

Kevin O'Connor, MD: So we like to treat pediatric strokes the same as adult strokes from the standpoint that overall time is brain. And there are several things that we can do early on when people present with a stroke that we can't do when they show up late.

And the big emphasis is that those things can help us save as much brain tissue as possible. So to an extent, we want people to be aware that yes, children can have pediatric stroke, and for that reason, we should treat them like adults from that perspective, but there are several things that we need to be aware of that are important to the pediatric population that we don't tend to worry about as much for our adults.

The biggest one being the radiation that you can have in very small doses when we take pictures of your brain. There's a lot of different ways we can take pictures of your brain. One of those is using a CT scan, and that uses very small doses of ionizing radiation. When you're an older adult, we can tolerate that very well. People get those scans all of the time. But when you're, let's say, three months old, your brain's still developing. So we want to be much more cautious and judicious when we're using that type of imaging. And we'll typically do different types of imaging, so that we can avoid radiation. So from an overall perspective, we do want to have a more adult like approach to children, particularly from the emphasis on awareness and time is brain, but then there are those subtle nuances that we always keep in mind because we don't want to treat children exactly like we would somebody that's an older adult.

Host: Yeah, that makes complete sense. You said in our last podcast, you know, it's incredibly rare between one in three in a hundred thousand, but of course, if it's your kid, then it's really important to you to, for the awareness of pediatric strokes, the treatment of pediatric strokes. And as you're saying, time is brain. It doesn't matter whether you're really small or you're an adult, time is brain and reversing the effects of strokes is really what's at stake here.

So let's talk about the parents of children who may be at higher risk and why they should be worried about pediatric stroke.

Kevin O'Connor, MD: So the children that tend to be at a higher risk for pediatric stroke, are going to be children that have in particular, heart disease, or congenital heart disease. There are, there are certain types of congenital heart conditions that are more likely to increase your risk of stroke compared to, other types of congenital heart disease. And we won't get into the litany of all those particular conditions, but having children with underlying heart conditions is a known risk factor. We also know that children that have infections that particularly involve the head and the neck, and we tend to think of these as a really bad ear infection, not your run of the mill ear infection, but like the really bad ones, really bad sinus infections can increase your risk of stroke because those infectious processes are right next door to the blood vessels in the brain itself, so that can cause nearby injuries.

And then sometimes, children just have a stroke and we don't know exactly why up front and then we like to do all of the investigations to try to determine, well, what was it that caused this stroke? And sometimes we find underlying genetic conditions. Sometimes we find things that are medical problems but aren't necessarily genetic.

Host: Yeah, it's interesting. And we've covered some of the ground that we covered last time and want to talk a little bit about what UK is doing specifically to improve pediatric stroke care.

Kevin O'Connor, MD: So the first thing that we're doing, is having a process to manage and treat or triage the children that show up to the hospital with what we can broadly call acute neurologic symptoms. And those are things like you're having sudden difficulty walking or balance problems, you're having vision trouble, either your eyes aren't working right or you're having blind spots in one eye, you're having facial droop, you're having problems with your arm or your leg on one side, either a strength problem or a sensation problem, or you're having some sort of speech problem. So if you have one of those things, and we use the mnemonic BEFAST, B-E-F-A-S-T to emphasize the balance, ears, face, arm, leg, speech, with a bigger emphasis on the end at time, for the time is brain.

So when children show up with a problem that kind of fits into one of the, one or more of those categories, we have an algorithm that we work through to make sure that we're evaluating them properly with the right type of imaging, because again, we don't want to use radiation unnecessarily. But in cases where you could be a candidate for some of the acute treatments, like the clot busting medicine that we'll often hear about in the community, or a thrombectomy, where we can go in and essentially pull out part of a clot, the algorithm helps us determine if those things are indicated; and if they are, whether or not you're going to be a good candidate for those things.

And part of a larger aspect of what UK is doing to help manage pediatric stroke would be disseminating that type of managing algorithm to a lot of the hospitals in Kentucky that don't commonly see pediatric patients at all. Because when we think of the children's hospitals in Kentucky, it's University of Louisville Northern Children's, it's the Kentucky Children's Hospital.

But outside of that, they're just regular hospitals. And if your child is two or three hours away from the University of Kentucky, you're probably not going to want to drive two to three hours to come to the Children's Hospital Emergency Department. You'll want to go to your local emergency department.

And they may not see very many pediatric patients, and they probably definitely aren't going to see very many pediatric stroke patients. So we've partnered with a lot of the hospitals to have this algorithm available for them. It helps them work through the same process as if the patient showed up to the UK emergency department, and it gives them a way to reach out directly to us at UK or at the University of Louisville, depending on which half of the state you're in, so that we can do a better job managing these patients as early as possible because we want to reduce the potential for disability from a pediatric stroke.

Host: Yeah, and I wanted to just drill down a little bit more with the algorithm. How does it help to address the limitations in treating pediatric stroke?

Kevin O'Connor, MD: One of the biggest limitations in treating pediatric stroke, and it kind of ties into one of our limitations in treating stroke in general, is patients presenting to smaller, rural, regional hospitals that don't have access to a lot of resourcesand this algorithm helps address one of the biggest deficits throughout the state in terms of a resource, which is a pediatric neurologist or child neurologist who's familiar with pediatric stroke and children with acute neurologic deficits.

And so if a child were to show up to a smaller regional hospital, what we like to highlight about this algorithm is here's the numbers that you can call us and we will work with you through the rest of this algorithm. And what that algorithm is designed to help determine, do we need to image this child?

And if we do need to image this child, based on whatever that imaging shows, should we be giving the clot busting medicine, which many of our regional hospitals do on a regular basis for adult patients, but they will be understandably cautious about doing that with a pediatric patient. But when they're talking with us on the phone, we're going through the same algorithm with them.

We can walk them through that entire process. And if that child is two hours away from UK, but because of this algorithm, we're able to go through all the appropriate steps and we're able to administer that clot busting medicine before they leave that smaller hospital; that's an additional two hours of brain that we could potentially save, as opposed to the child traveling the two hours to come to UK, where they may not even be a candidate for that clot busting medicine anymore.

Because that's one of those ones where you got to show up pretty early on, we tell people within four and a half hours of the symptoms starting, you can still be a candidate for that clot busting medicine.

Host: Yeah, really amazing. And you can just see all the benefits, obviously, no wasted trips, hopefully, and getting to the closest emergency department as fast as possible, because we know about BEFAST and time is brain. Does that mean, Doctor, that just really just about any qualified medical professional at one of these maybe smaller rural hospitals, if they've got that algorithm and they make that phone call that really anyone can help a child?

Kevin O'Connor, MD: That's exactly right. We designed this algorithm to be used at essentially any emergency department, any hospital. You could even use it in a clinic. If you regularly see pediatric patients in a clinic setting, if you have somebody that's a pediatric person and they have the acute onset of neurologic symptoms, and you think, man, this could be a stroke; you can absolutely pull out that algorithm. Give us a call again, whatever part of the state you're in. We kind of arbitrarily broke it up. If you're on the left side, you can call University of Louisville Norton's. If you're on the right side, you call UK. We'll walk you through the algorithm and we can, together make sure that that child gets good treatment.

Host: Yeah, I love it. I mentioned to you before we did our last podcast, the first one we did, that, you know, I've done a lot of stroke podcasts, but not pediatric stroke because it is less common. And it fairly rare. So this has all been really educational. I'm sure it has been for listeners as well.

We tried to emphasize here the BEFAST, time is brain, reversing the effects of stroke especially in this pediatric population using the algorithm. It's just all good stuff. So thank you so much.

Kevin O'Connor, MD: Thank you for having me.

Host: And for more information, visit our website at ukhealthcare.com. And that wraps up another episode of UK HealthCast from UK HealthCare. Please remember to subscribe, rate and review this podcast and all the other UK HealthCare podcasts. I'm Scott Webb. Stay well.