P044: WHEN TIME MATTERS IN A REMOTE LOCATION: PEDIATRIC STROKE AND THE DIFFICULT AIRWAY
Erick Rodriguez, MD1; Nelson V Guevara, ScM2; Giuliana Orihuela, MD3; Luis I Rodriguez, MD, FASA3
1Jackson Memorial Hospital; 2University of Miami Miller School of Medicine; 3Nicklaus Children's Hospital
Background: Pediatric stroke is a rare but serious neurological emergency, with an incidence of approximately 2 to 13 cases per 100,000 children each year. Although it is less common than adult stroke, pediatric stroke poses a significant risk of morbidity and mortality, often resulting in long-term neurological deficits. Early recognition and intervention are critical; however, the diagnosis is frequently delayed due to the wide variability in clinical presentation and overlap with more common pediatric conditions.
Case: We present the case of a morbidly obese teenage female with a history of grade II fibrillary astrocytoma complicated with a secondary high-grade glioma, epilepsy, and right hemiparesis. She experienced an initial transient episode of slurred speech, blurry vision, and decreased responsiveness. As per parents, patient had history of difficult intubation in a prior surgery in her country of origin. Due to recurrent episode of slurred speech and agitation, was brought to emergency department due to concerns for stroke. Patient had recent food intake while on a GLP-1 inhibitor (Ozempic) created significant airway management challenges, requiring anesthesia involvement for safe neuroimaging. A stroke alert was initiated in the ED. Due to patient inability to tolerate CT scan, patient was sedated and became agitated, and at this point, anesthesia was called to CT to help manage patient and provide care to obtain neuroimaging.
Initial neuroimaging showing vasogenic edema related to her known neoplastic disease.
The differential diagnosis included non-acute hemorrhage and radiation-induced leukoencephalopathy. Further MRI evaluation revealed stable postoperative changes without signs of acute ischemia. Given her complex medical history, additional workup included a bubble study via echocardiography, which was negative for intracardiac shunting, and a CT angiography (CTA) that demonstrated internal carotid asymmetry without acute vascular pathology. The patient was started on aspirin and continued dexamethasone for managing cerebral edema.
Discussion: This case highlights the necessity of a systematic approach to pediatric stroke that includes early recognition, differential diagnosis, and multidisciplinary coordination. Pediatric stroke can arise from a variety of causes, including congenital heart disease, sickle cell disease, infections, genetic disorders, and, as in this case, oncologic and treatment-related factors. We review essential aspects of pediatric stroke, including ischemic versus hemorrhagic etiologies, risk factors, and diagnostic modalities such as MRI, CTA, and echocardiography. Given the variability in stroke presentation among different ages, standardized strategies—such as the ABCDE framework and rapid MRI protocols—are vital for timely intervention. Furthermore, we emphasize the importance of stroke protocols in guiding antithrombotic therapy, neurocritical care, and the indications for anesthesia involvement in imaging and airway management.
It is critical, to quickly assess the patient and decide what is the best imaging modality to make the diagnosis, but also balancing the risk of causing harm due to risks associated with the patient, in our case: risk of loosing airway, full stomach and risk of aspiration.
By examining this case within the framework of current pediatric stroke guidelines, we underscore the significance of early recognition, multidisciplinary coordination, and adherence to standardized stroke pathways in optimizing outcomes for pediatric patients.