Cardiac ICU neuromonitoring in infants with CHD leads to early arterial ischaemic stroke recognition: a single centre experience

Abstract Objectives: Evaluate the utility of comprehensive neuromonitoring to allow for early identification of arterial ischaemic strokes in high-risk critically ill infants with CHD. Methods: Design: Single-center, retrospective review of Pediatric Cardiac Critical Care Consortium registry data, internal cardiac ICU database, and electronic health records. Setting: Tertiary care children’s hospital cardiac ICU. Patients: Patients <6 months old who underwent surgical and/or catheter intervention from 01/01/2016 to 12/31/2022. Results: Of 362 patients, 25 were diagnosed with arterial ischaemic strokes. The latter had more complex CHD and underwent higher risk operations: 60% ( n = 15) had single ventricle CHD versus 15% ( n = 50) of controls ( P < 0.001); 88% ( n = 22) underwent STAT* 4 or 5 operations versus 32% ( n = 108) of controls ( P < 0.001). Strokes were identified in 13 patients (52%) because of acute post-procedure neuromonitoring, including head ultrasound ( n = 5) and continuous video electroencephalography ( n = 8). Strokes manifested clinically in less than half of the episodes (11 of 25), and focal neurologic signs were noted in 20% (5 of 25). A head ultrasound first diagnosed 60% of arterial ischaemic strokes (15/25); 36% (9/25) were diagnosed by head CT, and 4% (1/25) were diagnosed by MRI. Conclusions: Comprehensive neuromonitoring in high-risk critically ill CHD patients leads to identification of arterial ischaemic strokes even in the context of significant haemodynamic lability and limited neurological examination secondary to sedation and neuromuscular blockade. Head ultrasound is useful as an initial screening modality, with advanced imaging used to confirm an injury or in cases of high clinical suspicion.