• Mark T Mackay, Zhi Kai Chua, Michelle Lee, Adriana Yock-Corrales, Leonid Churilov, Paul Monagle, Geoffrey A Donnan, and Franz E Babl.
• From the Department of Neurology (M.T.M.) and Emergency Department (Z.K.C., M.L., F.E.B.), Royal Children's Hospital Melbourne, Parkville; Murdoch Childrens Research Institute (M.T.M., F.E.B.), Parkville; Florey Institute of Neurosciences and Mental Health (M.T.M., L.C., G.A.D.), Parkville; University of Melbourne (M.T.M., Z.K.C., M.L., L.C., P.M., G.A.D., F.E.B.), Parkville, Australia; and Hospital Nacional de Ninos (A.Y.-C.), San Jose, Costa Rica.
• Neurology. 2014 Apr 22; 82 (16): 1434-40.

ObjectivesTo determine symptoms, signs, and etiology of brain attacks in children presenting to the emergency department (ED) as a first step for developing a pediatric brain attack pathway.MethodsProspective observational study of children aged 1 month to 18 years with brain attacks (defined as apparently abrupt-onset focal brain dysfunction) and ongoing symptoms or signs on arrival to the ED. Exclusion criteria included epilepsy, hydrocephalus, head trauma, and isolated headache. Etiology was determined after review of clinical data, neuroimaging, and other investigations. A random-effects meta-analysis of similar adult studies was compared with the current study.ResultsThere were 287 children (46% male) with 301 presentations over 17 months. Thirty-five percent arrived by ambulance. Median symptom duration before arrival was 6 hours (interquartile range 2-28 hours). Median time from triage to medical assessment was 22 minutes (interquartile range 6-55 minutes). Common symptoms included headache (56%), vomiting (36%), focal weakness (35%), numbness (24%), visual disturbance (23%), seizures (21%), and altered consciousness (21%). Common signs included focal weakness (31%), numbness (13%), ataxia (10%), or speech disturbance (8%). Neuroimaging included CT imaging (30%), which was abnormal in 27%, and MRI (31%), which was abnormal in 62%. The most common diagnoses included migraine (28%), seizures (15%), Bell palsy (10%), stroke (7%), and conversion disorders (6%). Relative proportions of conditions in children significantly differed from adults for stroke, migraine, seizures, and conversion disorders.ConclusionsBrain attack etiologies differ from adults, with stroke being the fourth most common diagnosis. These findings will inform development of ED clinical pathways for pediatric brain attacks.

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