Key points
- Sudden focal deficit (one-sided weakness or numbness, facial droop, speech, vision or new ataxia) = stroke until proven otherwise.
- Record the exact onset or last-known-well time; check a point-of-care glucose immediately.
- Preferred imaging: hyperacute brain MRI with MRA of the head and neck; use noncontrast CT (with CTA) if MRI would cause delay.
- A head CT without blood does not rule out ischemic stroke.
- Alteplase dose: 0.9 mg/kg (max 90 mg), 10% IV over 1 minute and 90% over 60 minutes; 50 kg = 45 mg (4.5 mg + 40.5 mg).
- A large-vessel occlusion can justify thrombectomy assessment beyond 4.5 hours.
- Start transfer to a pediatric stroke center immediately, in parallel with stabilization and tests.
Recognize stroke in a child
- Warning signs: sudden unilateral weakness or numbness, facial droop, speech or language change, vision loss or double vision, new ataxia.
- Children may also present with seizure at onset, headache or reduced consciousness; a focal seizure does not explain away weakness that persists.
- Risk factors: congenital heart disease, sickle cell disease, clotting disorders, recent head or neck trauma (arterial dissection), recent varicella or other infection (focal cerebral arteriopathy), and prior arteriopathy.
- Time: record the exact onset or the last-known-well time; it drives every treatment decision.
- PedNIHSS measures how severe the neurologic deficit is; it does not by itself decide treatment.
First actions
Think: time → alert the stroke team → glucose → brain and vessel imaging → treat or transfer. These run in parallel, not one after another.
- ABCs: keep oxygen saturation, blood pressure, temperature and glucose normal, and treat seizures.
- Point-of-care glucose at once: hypoglycemia is a treatable mimic.
- Blood tests: CBC, CMP, PT/INR, PTT, plus magnesium and phosphorus; type and screen if intervention is possible; hemoglobin S percentage in sickle cell disease.
- If the hospital does not offer pediatric stroke care, start the transfer right away; do not wait for every result.
- In sickle cell disease, acute ischemic stroke is treated with urgent exchange transfusion, with hematology.
Imaging
- Best study: a rapid (hyperacute) brain MRI with diffusion imaging plus MRA of the head and neck, often without contrast.
- If MRI cannot be done quickly: noncontrast head CT plus CT angiography of the head and neck.
- CT is good for blood but often normal in early ischemic stroke, so a CT without hemorrhage does not exclude stroke.
- Negative first imaging with a persistent focal deficit: the work-up is not finished; reassess urgently with the stroke team.
Mimics and other urgent diagnoses
| Condition | Point |
|---|---|
| Hypoglycemia | Check glucose first; correct it and re-examine |
| Todd paresis after a seizure | Weakness fades over hours; persistent deficit still needs imaging |
| Migraine with aura or hemiplegic migraine | Often has a history of similar episodes; a diagnosis of exclusion |
| Intracranial hemorrhage | Not a mimic: a stroke type with different treatment (no thrombolysis) |
| Cerebral venous sinus thrombosis | Not a mimic: headache, seizures, papilledema; treated with anticoagulation |
Reperfusion: alteplase and thrombectomy
Reperfusion in children is decided by a pediatric stroke team with experience in these treatments. Eligibility depends on timing, a disabling deficit, imaging that confirms ischemic stroke and the absence of contraindications together, never on one score.
- The 2026 AHA/ASA acute ischemic stroke guideline added a focused pediatric section; IV alteplase may be considered in selected children with confirmed ischemic stroke, a disabling deficit and treatment within 4.5 hours.
- Alteplase dose: 0.9 mg/kg total (maximum 90 mg): 10% as an IV bolus over 1 minute, then 90% over 60 minutes.
- Example: 50 kg → 45 mg total: 4.5 mg over 1 minute, then 40.5 mg over 60 minutes.
- A large-vessel occlusion on CTA or MRA prompts urgent thrombectomy assessment, and may still be treatable beyond the 4.5-hour alteplase window.
Common questions
Can children get tPA for stroke?
Selected children can. The decision is made by an experienced pediatric stroke team for confirmed ischemic stroke with a disabling deficit within 4.5 hours, at 0.9 mg/kg (max 90 mg).
What are the most common stroke mimics in children?
Hypoglycemia, Todd paresis after a seizure and migraine with neurologic symptoms. Hemorrhage and venous sinus thrombosis are not mimics but other urgent stroke diagnoses.
Study this topic
Sources
- AHA/ASA 2026: Guideline for the early management of patients with acute ischemic stroke (Stroke)
- AHA/ASA 2019: Management of stroke in neonates and children, scientific statement (Stroke)
Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.