Accuracy and Reliability of Stroke Diagnosis in the Pediatric Emergency Department.
Access to acute stroke interventions in the emergency department (ED) relies on correct clinical diagnosis. Our aims were to determine the accuracy and reliability of pediatric ED physician diagnosis of childhood stroke and other conditions presenting with brain attack symptoms.



Prospective study of consecutive children aged 1 month to 18 years presenting to the ED from June 2009 to December 2010 with focal neurological deficits. Accuracy (sensitivity, specificity, and receiver operator characteristic curves [ROCs]) and interrater agreement (κ) were determined, between ED physician diagnoses, as recorded in the electronic hospital administrative software system, and final neurological diagnosis, after completion of diagnostic work-up.



Two-hundred eighty-seven children with 301 consecutive presentations were recruited. The most common final brain attack diagnoses included migraine in 84 children, first seizure in 48, Bell's palsy in 29, stroke in 21, and conversion disorders in 18 children. Sensitivity of ED physician stroke diagnosis was 62%, and specificity was 98% (ROC, 0.8). Inter-rater agreement for ED physician and final stroke diagnosis was substantial (κ=0.61). ED physician diagnostic accuracy and reliability was highest for Bell's palsy (ROC=0.98; κ=0.96), and lowest for central nervous system demyelination (ROC=0.5; κ=-0.01) and cerebellitis (ROC=0.50; κ=0.50).



ED physician diagnostic accuracy and reliability varies considerably across disorders presenting with brain attack symptoms. Clinical recognition tools are required to assist pediatric ED physicians with diagnosis of stroke and other serious neurological disorders.
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.). mark.mackay@rch.org.au.
Mark T
MT
Mackay
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
Adriana
A
Yock-Corrales
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
Leonid
L
Churilov
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
Paul
P
Monagle
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
Geoffrey A
GA
Donnan
From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
Franz E
FE
Babl
D000293:Adolescent; D020330:Bell Palsy / Q000175:diagnosis; D001927:Brain Diseases / Q000175:diagnosis*; D002524:Cerebellar Ataxia / Q000175:diagnosis; D002648:Child; D002675:Child, Preschool; D003291:Conversion Disorder / Q000175:diagnosis; D003711:Demyelinating Diseases / Q000175:diagnosis; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008881:Migraine Disorders / Q000175:diagnosis; D010372:Pediatrics / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D020521:Stroke / Q000175:diagnosis*
brain attack; cerebrovascular diseases; child; emergency service, hospital; stroke