Brain to Bedside
To expand neurological knowledge and clinical insight among healthcare providers in Utah and surrounding outreach regions through accessible and expert-led conversations.
Brain to Bedside
Episode 4: New Pediatric Stroke Guidelines Released!
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In this episode of Brain to Bedside, guest host Dr. Lee Chung sits down with Dr. McKenna Coletti to break down a major milestone in stroke care: the first year the American Heart Association has released formal stroke guidelines for pediatric patients.
Drawing from Dr. Coletti’s recent conference presentation, this conversation focuses on what these new guidelines mean for frontline clinicians and how they can be applied in real-world settings. Pediatric stroke has long lacked standardized, evidence-based guidance, and this episode highlights how that gap is beginning to close.
Together, they walk through the most important updates, ongoing uncertainties, and the practical implications for recognition, imaging, and early management. The discussion emphasizes how healthcare teams can use this new guidance to improve consistency, reduce delays, and strengthen systems of care for children presenting with stroke.
Hey everyone, welcome back to Brain to Bedside. We are happy to have you here and we are happy to have our presenters today. We have Dr. Chung back with us today, and then we have Dr. Colletti with us. And I'll give them a second to introduce themselves here in just a minute. For context, locally here in Utah, we just recently had a stroke conference and a neurorehab conference. And so our topic today is to talk about the highlights of that conference and our key takeaways. So for the rest of the episode, I'm going to turn the time over to Dr. Chung and Dr. Colletti.
SPEAKER_00Thank you, Jamie, and thank you for everyone for joining us. We're really lucky to have Dr. McKenna Colletti joining today. She is a child neurologist who's completing her subspecialty training in stroke, which is something that I had not heard of very often before. And so I'd love to ask about that. First of all, Dr. Colletti, I'd love to hear a little bit about how you became interested in pediatric stroke and what your pathway has been like to get to where you are now.
SPEAKER_02Yeah, thank you, Dr. Chung. Like Dr. Chung mentioned, I'm a pediatric neurologist by training, and that's what I did my residency in and doing my fellowship now in stroke. And I would say this path has been a little bit windy. I initially matched actually in general pediatrics, knowing that I love taking care of kids, and that was just my favorite population. But in my first year of residency, I realized like all the neurologic cases were the most interesting to me, and more specifically really sick kids in the ICU or the NICUs. So that kind of branched me that direction towards neurology. And it was really on my adult stroke year and my first adult stroke month that I got to be on the vascular team and take care of patients with stroke. And I just loved going to brain attacks. I loved the acute management and the triage part of that. And so, and then kind of looking around a little bit, I really saw that there was a lot of work to be done on the pediatric stroke side in terms of recognition and treatment options and just how they can get access to care. And so I became really interested in that. And that kind of brought me to my fellowship.
SPEAKER_00Fantastic. A lot of our listeners are used to treating adult patients. Many have probably never met a child neurologist, let alone a child vascular neurologist. How common really are vascular disorders in children?
SPEAKER_02Yeah, that's a really awesome question. And I think I talk to sites with our new telestroke program all the time, and people will say things like, I didn't even know kids could have strokes. And I think that's really common perception. Um, but about 10 in 100,000 kids in the US will have an arterial ischemic stroke. And so many more having other vascular problems. Um and I would say here in the Mountain West, I think that number is probably even higher based on like the more data we've been collecting over the last couple of years. Um, so very it's, you know, not as common as adult stroke, but it's something that happens and it's an emergency that needs to be cared for specifically.
SPEAKER_00Absolutely. Um, I I would expect that probably most folks aren't thinking about strokes in children until it happens. And then all of a sudden, you know, we wish that we had, you know, maybe paid a little more attention or or um had a little better memory of who to call. Um, so I really appreciate you joining us. Last week you gave a fantastic presentation about updates to pediatric stroke guidelines. Can you tell us what that landscape has been like up before this year?
SPEAKER_02So we've come a really long way in terms of thinking about pediatric stroke and gathering information about how we can best treat these kids, but there's still a lot that we don't know. Kind of up till this point, we've have no randomized control trials for things like Ivy thrombolytics, for example. Um, there was one that was tried to be completed, and basically what we got to was uh we don't think it causes harm, but we really don't have any evidence for benefit yet. But recently there's been more trials, they're all retrospective kind of trials about thrombectomy that have really showed that you can make a big impact with when we treat kids with thrombectomy in terms of their functional outcomes. And so we've never had, we've never been included in the guidelines for acute stroke management on from the adult side. And we've really had, you know, we don't have as big of a centralized source to uh promote guidelines on the pediatric side. So I think it's such a big deal that we were kind of included in the guidelines this time to just get everybody thinking about pediatric stroke a little bit more.
SPEAKER_00That's great. I think that um uh there's a couple key details I'd love to pick your brain about. Um you mentioned IV thrombolysis in children. Can you tell us a little bit about what kind of data we have and what the the new recommendations are from the guidelines?
SPEAKER_02Yeah, so the data again, like it's just not uh that amazing to say that we can cause that we are gonna help when we give IV thrombolytics the benefit. We haven't proven to be there necessarily, um, but we do think it's pretty safe. And in kind of the safety studies with TPA, we have a lot more data. With TNK, we really have nothing because we really couldn't get TPA quite off the ground before everybody switched to TNK. But we're we're pretty confident that it's not going to cause harm and we kind of steal some of the adult data to say maybe it's helpful. Um, but the new guidelines do say that it's reasonable to give IV thrombolytics to anybody 28 days to 18 years if they present within four and a half hours. That's it's a to be recommendation in the guidelines. So uh that's pretty strong. I would say that when we talked about this when I went to ISC with a lot of other pediatric stroke neurologists across the country, people were a little suspicious of the 28 days, like giving IV thrombolytics that young. Not that we don't think it's safe, but it's pretty tricky to identify a last known well in a baby that young. And so those kind of add additional challenges. And in the absence of knowing if there's benefit, are a lot of families going to want to take on that risk? And I think we're still not totally sure, but certainly it's something that we should be thinking about if kids are presenting within the four and a half hour window.
SPEAKER_00What do you see are some of the pros and cons of TNK versus TPA specifically for children?
SPEAKER_02Yeah, I think uh in terms of the pros for TPA, um, I think is that we have a lot more safety data. So we we are a lot more confident that it's very safe. Um, we again we use it in a lot of cardiac um for a lot of cardiac indications in kids, so we know that even high doses can be quite safe. Uh the benefits for TNK is we think that kids actually have a higher uh fibrogen activity level and that is a little bit better bound with the TNK for longer. So maybe we didn't see benefit with the kids that we've given TPA before because we weren't given high enough dose and people are worried about giving a higher dose. But maybe TNK would be something that's you know more beneficial at the lower dose, um, given it's longer activity on the fibrinogen. So that's the thought. I think it's all a little bit theoretical right now. Um, but of course, another benefit is that most of these kids, if you're gonna have a stroke at a center that's not uh, you know, a big children's hospital, those kids are gonna have to move. They're gonna have to be transported. And so being able to give T and Kane a one-time bolus and then transferring them is a huge benefit without having to wait.
SPEAKER_00You've been training at primary children's hospital for uh many years now, taking care of kids with stroke. Can you give us some insight into how primary children's uses thrombolysis and how that is similar or different to the way the guidelines were written this year?
SPEAKER_02Yeah, I can for sure. And I think one thing to mention that is a lot different than how we use IV thrombolysis in adults is that in kids, we do not, we never give it unless we have a proven stroke. And so that means like an you need an MRI before we can give it, which again adds delays to the, I mean, we can give it if there's a large vessel occlusion. So you either have to have an occlusion in the artery or we have a confirmed stroke on the brain MRI. And so again, that can that eats away into your time trying to get an MRI, especially in a kid that might need to be under general anesthesia or sedation to be still for an MRI. So we often run out of time to give the thrombolytic. But I would say honestly, we've only, I think I've only given ivathrombolysis maybe two times in a pediatric patient over at primary children's hospital. So it's not frequent. Um, right now, our our um pathway says that anybody over the age of 12 we feel comfortable giving TNK to. Everybody under the age of 12, if they come in within the window, would get TPA for a stroke. Um, but it's because of the unknown benefit, I think we are trying to identify kids that will rapidly um that need to go to EVT, but we're not necessarily pushing so hard for thrombolysis.
SPEAKER_00I see. And um, are there differences in the way primary children's uses TNK versus TPA compared to many other children's hospitals around the country?
SPEAKER_02Yeah, and that's another thing that we talked about at ISC. And I think everybody's a little bit all over the map right now. Some facilities are like, we are sticking to TPA and we're not doing TNK until we have more data. And I think some people are using this 12-year-old, like random kind of, you know, we think that they have some more similar physiology to adults, and some kids I some places we're using a 16-year-old cutoff. I think what's super tricky, especially as a site that re does a lot of telestroke to other sites, if if someone presents into a hospital that primarily takes care of adults, they're not going to have TPA on. So your choice is kind of TNK or nothing for those kids. And so we want to be as inclusive as possible to give kids the option to get a good therapy if it's helpful for them without, of course, causing harm. So it seemed like everybody was scrambling to write protocols to decide what to do when I talk to them at ISC. So it's hard to say.
SPEAKER_00Yeah. Yeah. It's interesting how these um when once the guidelines come out, sometimes it introduces more uncertainty into the way folks are doing things and they have to change their protocols. And so it generates, I think, a lot of um soul searching as far as institutions. Um, you mentioned thrombectomy for children. Tell us a little bit more about that and what types of patients the guidelines say are reasonable to consider that treatment.
SPEAKER_02Yeah, so what we kind of know so far about thrombectomy in kids is like I mentioned, that it's helpful. We have this information from there's the a couple of retrospective trials for kids that were included in the IPSS or the International Pediatric Stroke Study. And so they've kind of taken all these kids and ones that have gotten thrombectomy and kind of put them together and decided what their outcomes are. Um, recently there was a Safe Childs Pro study in 2024 that there was 170 kids that got EVT, and then they compared them to 91 kids that got best medical therapy. Again, most of these kids aren't getting IV thrombolytics, they're just getting things like aspirin and other things. And um the EVT group, NIH or PEEDS NIH, which is just the NIH for kids, but it's slightly different to include some of their capabilities, um, dropped by eight in the EVT group versus two in the medical management group. So that is a really, I think, big difference. Um, and this was at 90 days, was what was this outcome? And I think this really is kind of hammered home that wow, we can make a really big difference if we do thrombectomy early. I think the caveat with that is there's a lot of reasons that kids can have what appears to be a large vessel occlusion on an MRI or a CT. And it's a lot more likely to be an arteriopathy or a problem with the actual vessel than just a clot in that vessel than it would be in an adult. So I think we expect there to be benefit when we pull out that clot, but we worry about the fragility and the inflammation in those vessels too. So it's, I think I think of it as a less benign or the risk of it being a less benign procedure in children generally. So we have to be careful about who we select.
SPEAKER_00And your talk was really good because you mentioned how there's some controversy in that lower age limit. What is it that makes that lower age cutoff difficult to know? Is it anatomy? Is it lack of data? What is it that makes that difficult?
SPEAKER_02Yeah, so in the guidelines, um, the guidelines that came out, they said that in children over six years or like over six years can get thrown back to me if they are eligible. And that was a two-way guideline and then within six hours. And then also as a two-A guideline was kids over six, but they are six to twenty fours from symptom onset. But I think the controversial part is they included as a two B guideline, pediatric patients from 28 days to six years may be included within the 24 hour. And that is a little bit, that I think is the controversial thing. And um, that's the reasons for that is you know, kids are smaller, their vessels are smaller. We think at around the age of, you know, two-ish, you have almost an adult-sized head, but the vessels are still quite small until you're around six. There used to be the rule of sixes that people would talk about, like NAH of six, six years old, six hours of onset for pediatric stroke EVT. And so this kind of new guideline, you know, raises the question of whether we should drop that um age. Here at primary children's, we are considering thrombectomy in anyone over 12 months of age. That doesn't mean we haven't given, we haven't done thrombectomy in anyone that age, but that's a conversation that we have with the vascular neurosurgery team as well with the neurology team. Um, but 28 days feels really aggressive to me. And that's because those vessels are so small. And the equipment they we have to go after those clots is all adult equipment. Um, and then you have the added uh complication of sedating a really, really small child. And in some places, that means bringing a small child over to an adult hospital for adult anesthesiologists to sedate them. And then in our case, like in primary children's and some other places, there's an adult um neurosurgeon that comes over to do the procedure. We are super lucky at primary children's to have folks that are really interested in pediatric stroke care and have been doing a lot of cases over here. And so they have a lot more experience, but that's that's not necessarily the case in all of the country. So we you really need someone that knows what they're doing when they're going after those clots and small kids.
SPEAKER_00Thank you. Um, I recall that at ISC there were so many trials in adult stroke reperfusion that were announced. What makes it so difficult to do similar trials in the pediatric population?
SPEAKER_02Yeah, that is an awesome question. I think when we think about kids and the way that they reperfuse, at baseline, we just think they're better reperfusers. So when there's a deficit, we wonder, we don't know because we don't have any trials to show us, but we wonder if they just are having they have a lot better collaterals and do they just have better perfusion? So we really just don't even have the information to say what is abnormal in a kid versus normal. So if you see a really large perfusion deficit on a scan, is that going to just be made up because their their collaterals are so good and they're gonna improve by themselves more or not? And I think we don't know the answer to that. There is a really interesting study that's gonna come out of Sanford with um Dr. Sarah Lee pretty soon. Hopefully, where we've at primary children's have contributed some of our cases to um using either CT perfusion or just uh mismatch on MRI to try to see if we can answer that question a little bit better retrospectively. Um, but there's a lot of work to be done to be able to say what is a mix what kind of mismatch would be acceptable in a pediatric patient.
SPEAKER_00Uh that's fantastic to hear also that um here in Utah we're collaborating with centers across the country to um expand our understanding of of this natural history. Um you did mention something interesting about the natural course of children recovering from stroke. How does the stroke rehab principles differ when you're thinking about children versus when we're thinking about adults?
SPEAKER_02Yeah, I think there's, you know, so many things are the same, but I think some things are different. I think we run into a lot of problems trying to push stroke re pediatric stroke research forward because people assume kids are just gonna do better because they are they are so resilient and absolutely kids are resilient. But 70% of kids that have a stroke will live with a neurologic deficit for the rest of their lives. And that's a lot. That's a lot of kids, and that's a lot of years that they're gonna live with that deficit. So when we think of kind of like deficit per year, it's a big burden on, you know, those kids, those families, and society really as a whole. And so when we, you know, I we I feel like people ask me like, do you see miracles? I'm like, well, I see kids recover really well from stroke all the time. And I I'm always amazed at how well they do, but they do need support and they need, you know, appropriate rehab and developmental therapies to kind of reach their maximum potential. We talk a lot in the pediatric stroke world about neuroplasticity and the ability of um kids to kind of rewire around injuries. And it's true, but it requires rehab and occupational therapy and physical therapy and speech therapy to to do that rewiring. Um, so we uh that's always our kind of number one thing that we talk to families about when they leave is like you're not done when you leave. Like we we have a lot of work to do.
SPEAKER_00How well would you say guidelines have addressed pediatric stroke rehabilitation?
SPEAKER_02Oh, I don't think we're there yet. I don't think they've had we have a good um, I don't think we've included that, especially in the acute guidelines this time. But I'm super hopeful that in the future that we can have a little bit more information. We have some really nice um studies that have been got ongoing and just recently closed to kind of about constraint therapy for kids with early cerebral palsy. So that would include kids that had strokes really early on in life. So I think we actually have enough data to start to put that into action a little bit, but not quite there yet. So we'll hope for the next guidelines to have that included.
SPEAKER_00Yeah. Um, you also mentioned something really interesting, which was telestroke. Can you tell us a little bit about the developments in telestroke as it pertains to children?
SPEAKER_02Yeah. Um, so at Primary Children's, we've like just recently are rolling out our pediatric stroke program, or it has been rolled out now, but it still feels like we're rolling at all the times. So we're covering a really large geographical area at this point. I think pediatric stroke, I mean, telestroke is just extremely important. And I don't have to tell that to you, Dr. Chung, because that is your baby. But I think even in kids like with such a rare disease of so and so few specialists, it's so important to be able to have access to care to the people that know how to take care of that disease quickly. And so I it's I think it's gonna be very valuable. And then also sometimes just to be able to talk about a case with a specialist, the specialist to see the patient. And sometimes that means that they don't have to get transferred out of their home site, which happens a lot more often now that we're able to talk about it, before it's just like, I'm not sure, I'm just gonna send them. And then they end up here and we're like, well, you probably could have just like gotten a migraine cocktail and stayed there. Um, so I think I think for both things, you know, the kids that need to come are it's more likely that we're gonna get them. And the kids that don't need to come, it's more likely they get to stay where they can be closer to family.
SPEAKER_00That's fantastic. Um I talked to a lot of adult stroke neurologists about the topic of pediatric stroke just because it's so interesting to see differences in practice. But what I hear a lot is that um that child neurologists don't really seek input from adult stroke specialists and that a lot of people express that they wish there's maybe more communication or kind of more discussion between teams. What's your your view of that? What what do you want adult neurologists to know? What you know, when should they be reaching out, and vice versa. When do you feel that um there are situations where communication would improve care for patients?
SPEAKER_02Yeah, I think that's a really good question, a really tricky question. Uh again, like in pediatrics, it's a relatively rare disease. So there is probably some child neuro, even child neurologists that go, you know, many years with only seeing a couple of strokes or maybe even no strokes, or maybe not an acute stroke or a stroke that needs an intervention. And so, you know, the there, they can have limited experience in those areas and can be very, very worried and very uncomfortable. And so I think having knowing the avenue to reach out is super important. And I think on the other side, like we say in pediatric all the time, like kids are just not, or they're not just small adults. And so there's a lot of other, you know, pediatric physiology things at play that make a lot of other things besides stroke much more likely. So the mimic rate, like a stroke mimic, is so much more common in a pediatric patient than an adult patient. And so there's, you know, trying to suss those out and try to decide, you know, what's the stroke, what's you being a kid, what's your exam. I I'm hopeful that there's going to be, as we kind of, I think pediatric stroke as a subspecialty is something that's growing and we have more across the country. And I'm really, I see it as kind of a bridge between both of the worlds. And that's what I hope to do, you know, moving forward is kind of be able to at least be a communication bridge between the pediatric folks and the adult stroke folks. Because I think it's, you know, I agree with you, it's totally, it's very important. And there's things on both sides that everybody has blind sabats to.
SPEAKER_00Well, your passion and talent for kind of bridging both worlds certainly comes through, um, uh, as well as in the past year that you've been training on in both hospitals. Can you tell us what's next in store for you? What are your plans and where can we hope to see um your work move? In the future.
SPEAKER_02Yeah, thanks. Well, I signed a contract here at Primary Children's Hospital, so I'll be staying on, and I'm really hopeful to do some work with the adult folks on telestroke. Um, so you know, I want to be, I kind of want a foot in both places. I think it's so important for you know the communication between the two divisions, and I hope to be helpful with that. In terms of kind of research projects, there's just there's so much to be known about pediatric stroke. Um, and right now we are working on a trial here at primary children's. It's a focus trial that's through IPSS. So we are lucky enough to be a site, and we've been enrolling really heavily in that that looks specifically at um focal cerebral arteriopathy, which is a arteriopathy that happens in children. Actually, the most common reason that healthy children have strokes. So we're trying to learn more about that. I have a lot of interest in anticoagulation and acute stroke management in pediatrics and in CVST management. So we're trying to gather some of our patient data to make some, you know, to understand better what works best for kids. So that's where we're I'm moving right now, but always up for suggestions. I think if anyone thinks of a really good idea about what we should be studying in pediatric stroke next, let's add it to the list because we've got like a thousand things running at once, it feels like. But we are so excited that these guidelines came out. I think it's just really a like a nice stepping stone to really increase education about pediatric stroke nationwide through vascular neurologists and all the folks that take care of kids with strokes.
SPEAKER_00Well, thank you so much for joining us. This was super informative. Um, when folks are having uh are seeing patients with possible acute stroke, what's the best way that they could um reach out or get in touch with you or your team?
SPEAKER_02Yeah, so if you are living in Utah, you are probably part of our the pediatric stroke network. Um, so you can always telestroke us through there. Um, if you're not sure how to do that, you can always call primary children's and ask for the pediatric neurologist on call, and they can help triage that kind of those questions as well. But we have we should be able to get someone on the camera with you pretty quickly if there is a true stroke concern for pediatrics.
SPEAKER_00All right, Dr. Kaletti, thank you again for sharing your expertise and your passion with us. We are really delighted that you're staying here in the Inner Mountain region, and we really look forward to hearing of all the wonderful research and clinical work that you'll be participating in moving forward. Thanks again.
SPEAKER_02Thank you so much, Dr. Chung. It was really an honor to be here.