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With improved diagnostics and therapy, more children and adolescents with chronic and rare diseases are reaching adulthood. As a result, the need for adult medicine specialists for the continued care of these patients is increasing. In this survey, the patients at the University Hospital Innsbruck for Pediatrics (departments: Gastroenterology and Hepatology, Hematology and Oncology, Nephrology, Endocrinology, Diabetology, Rheumatology, Neuropediatrics, Inherited metabolic Disorders, Pulmonology and Allergology, Cardiology, and Cystic Fibrosis) who are due for transition were recorded. This survey was intended to serve as a basis for identifying potential improvements at the interface between pediatrics and adult medicine. As a cross-sectional survey, the number of patients in the pediatric specialty departments for the year 2023 was recorded. The total number (n = 12,078) was divided into under 16 years of age (n = 9635), between 16 and 18 years of age (n = 1288), and over 18 years of age (n = 1155). To explore the challenges of transition, semi-structured interviews were conducted with the heads of the pediatric specialty areas or with a deputy. Of the 12,078 patients, 21.83% of patients in the field of inherited metabolic disorders and 14.01% of patients in the field of cardiology (congenital heart defects) were over 18 years of age. In the fields of cystic fibrosis and hematology and oncology, the proportion of patients over 18 years of age was 53.87% and 19.67%, respectively. In these two fields, patients remain under pediatric care by agreement, and the care of these patients is subject to a clearly defined transition process within the clinic. In the remaining departments, a completed transition process can be observed. The interviews confirmed the available figures by describing the status of the transition in each department. In summary, the transition is already taking place in the majority of pediatric specialty departments. There is potential for further development in the fields of inherited metabolic disorders and cardiology, while the fields of cystic fibrosis and hematology and oncology have their own transition model. EINLEITUNG: Durch verbesserte Diagnostik und Therapie erreichen mehr Kinder und Jugendliche mit chronischen und seltenen Erkrankungen das Erwachsenenalter. Infolgedessen steigt der Bedarf an Erwachsenen-medizinischer weiterer Betreuung dieser Patientinnen und Patienten. In der vorliegenden Erhebung wurden die Patientinnen und Patienten an der Universitätsklinik Innsbruck für Pädiatrie (Bereiche: Gastroenterologie und Hepatologie, Hämatologie und Onkologie, Nephrologie, Endokrinologie, Diabetologie, Rheumatologie, Neuropädiatrie, angeborene Stoffwechselstörungen, Pneumologie und Allergologie, Kardiologie und Cystische Fibrose) erfasst, die einer Transition bedürfen, als Grundlage für das Verbesserungspotenzial an der Schnittstelle zwischen Pädiatrie und Erwachsenenmedizin. Als Querschnittserfassung wurde die Anzahl der Patientinnen und Patienten der pädiatrischen Spezialbereiche für das Jahr 2023 erfasst. Die Gesamtanzahl (n = 12.078) wurde eingeteilt in unter 16 Jahre (n = 9635), zwischen 16 und 18 Jahren (n = 1288) und über 18 Jahre (n = 1155). Zu den Herausforderungen der Transition wurden halbstrukturierte Interviews mit den Leitern und Leiterinnen der pädiatrischen Spezialbereiche bzw. mit einer Stellvertreterin oder einem Stellvertreter geführt. Von den 12.078 Betroffenen waren im Bereich Angeborene Stoffwechselstörungen 21,83 % Patientinnen und Patienten und im Bereich Kardiologie (angeborene Herzfehler) 14,01 % Patientinnen und Patienten über 18 Jahre alt. In den Bereichen Cystische Fibrose und Hämatologie und Onkologie lag der Anteil der über 18-Jährigen bei 53,87 % bzw. 19,67 %, wobei in diesen beiden Bereichen die Patientinnen und Patienten vereinbarungsgemäß in pädiatrischer Betreuung verbleiben und die Betreuung dieser Patientinnen und Patienten einem klar definierten Transitionsprozess an der Klinik unterliegt. In den restlichen Bereichen wurde der Transitionsprozess bereits vollzogen. Die Interviews bestätigten die vorliegenden Zahlen, indem sie die Transition auf dem jeweiligen Stand beschrieben. Zusammenfassend erfolgt die Transition bereits in einem Großteil der pädiatrischen Spezialbereiche. Ausbaupotenzial bieten die Bereiche Angeborene Stoffwechselstörungen und Kardiologie, während die Bereiche Cystische Fibrose und Hämatologie und Onkologie einem eigenen Transitionsmodell folgen.

X-linked adrenoleukodystrophy (X-ALD) is a rare monogenic disorder characterized by marked variability in clinical presentation, age at onset, and disease progression. A deeper understanding of its natural history and the relationship between biochemical markers and clinical phenotypes is essential for improving disease monitoring, patient counseling, and optimizing clinical trial design. In particular, the predictive value of very long-chain fatty acids (VLCFA) for clinical phenotypes has recently garnered increased attention. In this longitudinal, mixed prospective/retrospective, single-center study, we analyzed clinical and biochemical data from 364 patients with X-ALD (255 males). Parameters included clinical scores (EDSS, AACS), age at symptom onset, and disease manifestations, which were correlated with individual VLCFA levels. Patients with adrenal insufficiency (AI) exhibited significantly elevated VLCFA concentrations. Higher C26:0 levels were associated with faster progression (measured by EDSS); however, effect sizes were small and inter-individual variability considerable. Although initial symptom severity was comparable between sexes, males presented earlier and progressed faster. Among patients seen in early clinical stages (EDSS ≤ 4.5), disease progression rates were higher (males: 0.34 ± 0.77; females: 0.11 ± 0.11) than in those presenting at more advanced stages (EDSS > 4.5; males: 0.23 ± 0.33; females: 0.09 ± 0.10). We provide comprehensive data on the prevalence of disease manifestations and the natural course of X-ALD in a large adult cohort. The observed association between elevated VLCFA levels and adrenal insufficiency should be considered in future clinical monitoring and trial design. However, due to the small effect sizes and variability, VLCFA levels offer limited prognostic utility for individual patients.

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This study aimed to assess the availability of national transition guidelines in paediatric neurology across Europe and to provide a review of the existing literature. A mixed-methods descriptive study was conducted, combining a survey of national representatives of the European Paediatric Neurology Society and a scoping literature review. The survey, performed in 2021 with an update in 2026, assessed the existence of national or officially endorsed transition guidelines. The literature review (2002-2025) followed the Arksey and O'Malley framework and PRISMA-ScR recommendations. Thirty-six of 42 representatives responded to the 2021 survey; 66.7% reported no national transition guidelines in paediatric neurology, while 16.7% reported officially endorsed guidance. The literature search identified 23372 records, of which 132 publications were included in the final analysis. Most described centre-based transition models or general recommendations, while formal guidelines were rare. Drawing on the gaps identified through literature review and survey findings, this paper proposes a series of targeted recommendations to enhance the transition process in paediatric neurology. Transition guidance in paediatric neurology remains limited and heterogeneous across Europe. Specific recommendations are needed to provide guidance and enhance the effectiveness of this process. An EPNS-EAN Transition Task Force is currently developing a transition framework.

Dialysis-associated headache (DAH) is a common and recognized complication of chronic hemodialysis. We report a diagnostically challenging case of severe intradialytic headache in an adolescent with chronic kidney disease stage 5 and a history of ventriculoperitoneal shunt. A comprehensive evaluation excluded dialysis disequilibrium syndrome, biochemical and hemodynamic contributors, primary headache disorders, infection, vascular pathology, ophthalmologic causes, and shunt malfunction. Subsequent progression of focal neurological findings revealed a diffuse intramedullary spinal cord glioma. This case highlights the limitations of solely attributing refractory DAH to dialysis-related etiologies and underscores the importance of repeated neurological reassessment and multidisciplinary management in pediatric dialysis patients.

The diagnostic odyssey in rare diseases often involves the misinterpretation of genetic data, particularly when multidisciplinary approaches are lacking. This study illustrates the critical process of interpreting variants from next-generation sequencing (NGS) through a real-life case of a child misdiagnosed with Marfan Syndrome (MFS). The misdiagnosis was maintained for over seven years despite repeated clinical evaluations by different specialists. An initial clinical suspicion of MFS due to joint hypermobility at 3 years of age became a definitive diagnosis after an external laboratory reported a heterozygous variant in the MYH11 gene at age 5, despite the patient never fulfilling the established clinical diagnostic criteria for the disease. To provide an accurate diagnosis and end the family's diagnostic odyssey, a complete clinical and genetic reinterpretation was performed when the patient was 7 years old. The proband and 9 asymptomatic relatives were recruited for a functional study of the MYH11 c.5544_5548del, p.(D1848Efs*60) variant. The functional analysis demonstrated that the variant operates through a loss-of-function mechanism, leading to nonsense-mediated mRNA decay. While gain-of-function variants in MYH11 are associated with thoracic aortic aneurysms and dissections, loss-of-function variants are linked to autosomal recessive Megacystis-Microcolon-Intestinal Hypoperistalsis Syndrome (MMIHS). As a heterozygous carrier of a loss-of-function variant, the patient is asymptomatic for MMIHS and definitively does not have MFS. Currently, the 11-year-old child is progressing favorably without any notable pathology. This case exposes the entire diagnostic odyssey suffered by the patient's family and highlights three fundamental systemic errors: the critical delay in genetic counseling, the over-interpretation of NGS data by external laboratories lacking phenotypic context, and the health system's inefficiency in integrating clinical geneticists. Overcoming these barriers is essential for the true implementation of personalized precision medicine.

The large decrease in body weight with glucagon-like peptide-1 (GLP-1) medicines raises concern about a loss of lean body mass (LBM) and skeletal muscle. In this work, we present four pre-clinical studies and a proof-of-concept clinical trial that address this issue. We report that in obese mice, GLP-1 medicines predominantly reduce body fat alongside a small but significant decrease in LBM. Among lean tissues, loss of liver mass exceeds change in muscle mass. While absolute muscle mass and strength decrease, relative muscle mass and strength improve, resulting in better running performance. Interestingly, while atrophy is similar during immobilization, GLP-1 medicines have a distinct effect on the muscle proteome compared to calorie restriction. Patients with obesity on GLP-1 medicines improve their body composition without negatively affecting strength. Overall, in middle-aged mice and men, GLP-1 medicines slightly decrease absolute muscle values but positively impact body composition and mobility. The clinical trial is registered on clinicaltrials.gov (NCT05606471).

Aicardi-Goutières syndrome (AGS) is a prototypical type I interferon-driven neuroimmunological disorder in which immune-mediated inflammation causes progressive brain injury. Targeted immunosuppression with Janus kinase (JAK) inhibitors has shown clinical benefit, yet neurological outcomes remain difficult to quantify, and the interferon (IFN) score poorly reflects neuroaxonal damage. We investigated whether plasma neurofilament light chain (pNfL) and glial fibrillary acidic protein (pGFAP) serve as sensitive biomarkers of neurological involvement and response to immunosuppressive therapy. Plasma samples from 55 patients with genetically confirmed AGS and 55 age- and sex-matched healthy controls were analyzed using single molecule array assays. pNfL and pGFAP levels were assessed in relation to age, clinical disease severity, IFN score, and treatment with JAK inhibitors. Longitudinal samples before and during therapy were available from 11 patients. Treatment-naïve AGS patients exhibited significantly elevated pNfL and pGFAP levels compared with controls, and biomarker concentrations correlated with clinical disease severity. pNfL and pGFAP were strongly correlated with each other but showed only weak to moderate associations with the IFN score. Longitudinal within-patient analyses demonstrated significant declines in pNfL and pGFAP following initiation of JAK inhibitor therapy, whereas the IFN score remained unchanged. pNfL and pGFAP are sensitive indicators of neuroaxonal and astroglial injury in AGS, capturing neurological disease burden and treatment-associated changes more accurately than the IFN score. These findings support their use as objective biomarkers for monitoring immune-mediated brain injury and therapeutic response, and warrant validation in larger longitudinal studies.

Status epilepticus (SE) is a neurological emergency requiring rapid, stepwise treatment. In Japan, the Guidelines for the Treatment of Pediatric Status Epilepticus 2023 (GL2023) were published; however, real-world practice following their publication remains unclear. We conducted a nationwide, cross-sectional web-based survey of pediatric neurologists between January and March 2025. One representative from each institution reported institutional practices for the in-hospital management of pediatric SE. Institutions were stratified by annual SE case volume (≥20 vs. ≤19 cases). General management strategies, antiseizure medication selection, electroencephalography (EEG) utilization, and approaches to refractory and super-refractory SE (RSE and SRSE) were analyzed. A total of 136 institutions responded. Most institutions reported referring to GL2023 and initiating first-line treatment within 10 min of hospital arrival. Midazolam was the most commonly used first-line drug, with widespread use of non-intravenous routes. Phenytoin or fosphenytoin remained the most commonly selected second-line drug, followed by phenobarbital. For RSE, anesthetic coma therapy with midazolam and barbiturates was used at comparable frequencies. Overall, antiseizure medication selection did not differ by institutional case volume. In contrast, institutions managing ≥20 cases annually more frequently reported having institution-specific protocols, utilizing EEG in the emergency department, administering repeat doses of benzodiazepines, and having experience with advanced therapies for SRSE. Pediatric SE management in Japan emphasizes rapid treatment and flexible administration routes. Institutional experience is associated with differences in EEG utilization, protocol development, and SRSE management. Further improvement will require continued evidence generation, timely treatment implementation, and reduction of institutional disparities.

Functional neurological disorders (FND) present diagnostic challenges in pediatrics, with an actual incidence likely higher than reported. This study aims to analyze FND cases in our center to optimize patient management and treatment. We conducted a retrospective, single-center observational study of pediatric patients diagnosed with FND from January 2020 to January 2024. Data were collected from electronic medical records, focusing on patient demographics, symptoms, diagnostic tests, treatments, and outcomes. Statistical analysis included descriptive and inferential statistics to determine associations with recovery. We reviewed 37 patients, with a median age of 11 years and a predominance of females. Motor symptoms were most common (40.5%), followed by sensory disturbances and altered consciousness (29.7%). About 50% of patients presented more than one conversion symptom initially, increasing to 70% over all episodes. Complete symptom recovery was observed in 62% of patients, with recovery associated with motor and visual disorders. No significant associations were found between recovery and sex, psychiatric history, number of tests, or number of concomitant symptoms. Multiple complementary tests were performed in 78.3% of patients. Stress factors were identified in 59.4% of cases, mainly related to school problems. FND in children is complex, often involving multiple symptoms. Recovery was positively associated with motor and visual disorders. The high frequency of complementary tests suggests an exclusion-based diagnostic approach. Stress factors, particularly school-related issues, are common. These findings highlight the need for increased follow-up and multidisciplinary interventions to improve outcomes. Further research is necessary to enhance diagnostic and treatment strategies for pediatric FND.

Currently, no standardized anatomic magnetic resonance (MR) imaging protocol exists for detecting parathyroid adenomas. We analyzed various MR pulse sequences to evaluate their performance in visualizing histopathologically confirmed parathyroid adenomas in patients with primary hyperparathyroidism (pHPT) undergoing [18F]fluorocholine positron emission tomography (PET)/MR. This retrospective study included 128 adenomas in 110 patients with biochemically confirmed pHPT who underwent [18F]fluorocholine PET/MR at our institution between December 2020 and October 2023. Two radiologists independently characterized the lesions (as upper pole, lower pole, or ectopic adenomas). Surgical reports and histopathology served as reference standard. Lesion conspicuity, delineation, and size were compared on axial T1-weighted fast spin echo sequence (T1w FSE) and axial T2-weighted iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) sequence with water image reconstruction (T2w FSE flex water). Interreader agreement was determined using Cohen's kappa; differences were analyzed using Wilcoxon signed-rank test. Parathyroid adenomas had significantly higher conspicuity, superior delineation, and were larger (p&#x2009;<&#x2009;0.001) on T2w FSE flex water images compared to T1w FSE images. While these differences were maintained in the subgroup analysis for upper and lower pole adenomas, ectopic adenomas were of similar size on both MR pulse sequences (p&#x2009;=&#x2009;0.646). T2w FSE flex water offers significantly better visualization of parathyroid adenomas compared to T1w FSE, especially in orthotopic lesions. These results support the targeted use of such a limited MR protocol as part of PET/MR in the preoperative assessment of patients with pHPT.

Renal artery stenosis is an uncommon cause of secondary hypertension in infants and is rarely related to infectious etiologies such as cytomegalovirus (CMV). We report a 5-month-old infant who was admitted for afebrile status epilepticus and found to have severe hypertension. Imaging revealed focal stenosis of the right renal artery. Virological investigations confirmed active CMV infection. The patient was treated with intravenous ganciclovir, leading to normalization of blood pressure and complete radiological resolution of the stenosis within 6 weeks. CMV has a known endothelial tropism and may induce inflammatory vascular lesions. Renal artery involvement outside the transplant setting is exceptionally rare. This case highlights a reversible inflammatory vasculopathy related to CMV infection. CMV infection should be considered in infants presenting with unexplained renal artery stenosis. Early antiviral therapy may lead to complete reversibility without invasive intervention.

Background: Intravenous anti-infectives are an important part of postoperative care, but discrepancies between prescribed and documented administrations remain widespread and require systematic evaluation. Methods: In an exploratory study, prescribed and documented intravenous anti-infective administrations were retrospectively analyzed using patient charts, digital nursing reports and, in cases of deviations, consultations with the responsible staff. The discrepancies were classified into three categories: (I) documentation, (II) administration, and (III) a combination of both. The relationship between discrepancies and dosing interval, time of administration (weekday and shift assignment), and intravenous administration route was statistically analyzed (&#x3a7;2 test, residual analysis). Results: Of 5016 anti-infective administrations in 219 patients, 1135 (22.6%) had at least one discrepancy, of which 68.2% (774 of 1135) belonged to category I. Significant differences in the frequency of discrepancies between surgical wards and the dosing intervals were observed. On weekdays, 23.6% of drug administrations (832 of 3519) showed discrepancies compared to 20.2% on weekends (303 of 1497, OR = 1.22, 95% CI 1.05-1.42, p = 0.008). Although the early shift had the lowest administration rate, it showed significantly more discrepancies than expected (313.6 expected vs. 553 observed; adjusted standardized residual +18.1; p < 0.001). Drug administration via the peripheral venous route was more susceptible to discrepancies than the central venous administration route (23.2% [963 of 4149] vs. 19.8% [172 of 867]), OR 1.18; 95% CI 1.01-1.38; p = 0.031). Conclusions: Approximately a quarter of anti-infective administrations were affected by discrepancies, predominantly in category I, with the highest incidences occurring during the early shift and on weekdays. This requires a multi-step improvement program.

Pontocerebellar hypoplasia type 2A (PCH2A) is a rare autosomal recessive neurodegenerative disease caused by a specific pathogenic variant in the TSEN54 gene (p.A307S). Affected children show early but initially unspecific symptoms, diagnosed primarily through postnatal magnetic resonance imaging (MRI), with confirmation by genetic testing. This study examines the diagnostic process and key considerations for accurate diagnosis. We retrospectively collected data from 65 children (33 girls, 32 boys) with genetically confirmed PCH2A as part of a Natural History Study. Data were gathered via parental questionnaires, interviews, and medical reports. The cohort was divided into two groups based on year of birth: children born before (n = 30) and after (n = 35) the identification of the pathogenic variant in 2008. Prenatally, in 4 of 21 cases with specialized ultrasound (gestational weeks 12-32), only unspecific cerebellar abnormalities were reported. One fetal MRI (week 31) revealed clear cerebellar hypoplasia, in two others (week 21 and 31), slight cerebellar abnormalities were reported. Postnatal neurosonography often indicated disease features (26/54), later confirmed by MRI (62/63). Clinical symptoms appeared at a median age of 0 months (range 0-6 months), often initially suggesting acute rather than congenital issues. In the group born after 2008, median time from first symptoms to genetic confirmation was 5 months. PCH2A presents early with nonspecific symptoms. Prenatal and postnatal ultrasound imaging can fail to detect the condition, with MRI being the gold standard for diagnosis. Over time, the diagnostic process, including genetic confirmation, has become faster.

While prolonged impaired consciousness is often attributed to encephalopathy or meningitis, its occurrence and associated factors in patients with febrile status epilepticus without these conditions remain unclear. This study investigated the duration and determinants of impaired consciousness following febrile status epilepticus lasting&#xa0;&#x2265;&#xa0;30&#xa0;min in children treated with antiseizure medications. This retrospective multicenter study used data from the Febrile Acute Convulsion and Encephalopathy registry, a prospective multicenter consecutive case registry for acute encephalopathy and febrile convulsive status epilepticus in Japan. Children aged 6-60&#xa0;months with febrile status epilepticus lasting&#xa0;&#x2265;&#xa0;30&#xa0;min who received antiseizure medication were analyzed. Clinical data and early laboratory results were compared between prolonged (&#x2265;4&#xa0;h) and non-prolonged (<4&#xa0;h) impaired consciousness groups. Among 227 children with febrile status epilepticus lasting&#xa0;&#x2265;&#xa0;30&#xa0;min, the median time to recovery of consciousness was 176&#xa0;min, and 79 (34.8%) had prolonged impaired consciousness (&#x2265;4&#xa0;h). The two groups did not differ in age, sex, seizure duration, body temperature, history of febrile seizures, or number of antiseizure medications. Phenobarbital use was more frequent in the prolonged group. Laboratory abnormalities, including lower pH, lower base excess, higher creatinine, higher glucose, and higher ammonia were associated with prolonged impairment. Low pH was the only independent factor. In children with febrile status epilepticus&#xa0;&#x2265;&#xa0;30&#xa0;min, prolonged unconsciousness (&#x2265;4&#xa0;h) was associated with phenobarbital use and laboratory abnormalities, with acidosis as the sole independent predictor. Early recognition of delayed recovery may support timely clinical decision making and optimize emergency care.

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Infantile nystagmus (IN) is a common neuro-ophthalmological disorder that presents as early-onset involuntary oscillations of the eyes. Here, we report a novel genotype-phenotype correlation that associates sequence alterations in the calcium voltage-gated channel auxiliary subunit beta 3 (CACNB3) gene, encoding the CaV&#x3b2;3 protein, with idiopathic infantile nystagmus (IIN). Linkage analysis, whole exome and Sanger sequencing identified a homozygous missense mutation (c.316G>C) in CACNB3 co-segregating with IIN. Our calcium imaging experiments suggest that the p.Gly106Arg mutation in the Src homology 3 domain of CaV&#x3b2;3 may impair voltage-gated calcium channel function at the plasma membrane and may increase ligand-triggered inositol trisphosphate receptor mediated calcium release at the endoplasmic reticulum. Co-localization studies indicate reduced plasma membrane localization of the calcium channel. We propose CACNB3 to be a novel gene associated with IIN. Our findings point towards an important role of calcium-signalling in IIN and may contribute to deciphering its aetiology.

Growing evidence for reperfusion therapies in pediatric acute ischemic stroke (AIS) increases the importance of timely diagnosis within treatment windows. We therefore aimed to describe 24-year trends and associated factors of diagnostic delay. We conducted a nationwide retrospective cross-sectional study including 314 children aged 28 days to 16 years from the Swiss Neuropediatric Stroke Registry (2000-2023). The primary outcome was time from stroke onset to diagnosis (TOD). Trends for diagnoses beyond intravenous thrombolysis (&#x2265;4.5 hours) and thrombectomy (&#x2265;24 hours) windows were assessed with multivariable logistic regression, and for continuous TOD with robust linear regression. Prespecified covariates were retained in multivariable models if associated with the outcome in univariable analyses. Analyses were stratified by AIS onset location (out-of-hospital and in-hospital). Median TOD was 26.9 hours (interquartile range, 10.1-91.5) between 2000 and 2023. During this period, the proportion diagnosed beyond the thrombolysis window decreased significantly in the overall cohort from 90.9% to 77.5% (adjusted odds ratio per calendar year 0.94 [95% CI, 0.88-1.00]) and in out-of-hospital AIS from 88.1% to 74.1% (adjusted odds ratio, 0.91 [0.84-1.00]). No significant change was observed beyond the thrombectomy window diagnoses. Continuous TOD decreased significantly only in in-hospital AIS (&#x3b2;=-4.3 [-7.2 to -1.5]). Older age (&#x3b2;=-1.8 [-2.9 to -0.8]), higher pedNIHSS (&#x3b2;=-1.2 [-2.1 to -0.4]), and facial palsy (&#x3b2;=-19.4 [-30.2 to -8.5]) were associated with shorter TOD, and nonspecific symptoms (&#x3b2;=110.0 [72.5-147.5]) with longer TOD. Out-of-hospital TOD was shorter when patients presented to a stroke center compared with other presentation sites. Posterior-stroke symptoms were associated with diagnoses beyond the thrombolysis window. Despite decreasing proportions of beyond-thrombolysis window diagnoses in out-of-hospital AIS and decreasing TOD in in-hospital AIS, most diagnoses occur beyond reperfusion windows. Goals to decrease delay include raising awareness of posterior-stroke signs and AIS in younger children, and strengthening direct-to-stroke center pathways.

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