Delayed Recognition of Strokes

Harm range: Minimal permanent harm to death.

Symptoms and risk factors for pediatric arterial ischemic strokes (AIS) and intracerebral hemorrhage strokes (ICD) are many and varied, making recognition difficult.

Both types can present with headaches, altered mental status, focal neurologic deficits, and seizures.¹ Older children typically have focal neurologic signs, such as hemiparesis, aphasia, visual disturbance, or cerebellar signs. Infants and younger children more commonly have seizures, vomiting, and lethargy. ^1,3

Risk factors for pediatric AIS include arteriopathy, cardiac abnormalities or disorders, infection, hematologic abnormalities, and trauma.² The most common cause of ICH in children is ruptured vascular malformations. ¹

The goal of stroke care is to rapidly recognize and stabilize the child to minimize brain injury and treat reversible causes.

Contributing factors to delays in recognition may include:

• Varied clinical presentation based on the patient’s age, with younger children most likely exhibiting nonspecific symptoms
• Failure to recognize an acute change as a stroke symptom or misattributing the symptom due to anchoring bias (e.g., attributing to fatigue, dehydration, or sickle cell)
• Lack of awareness and clarity around activation of the stroke protocol or the code stroke process across departments
• Incomplete radiologic imaging
• Barriers in accessing consultative groups such as pediatric neurology or radiology (e.g., staffing issues, communication barriers)

The in-hospital mortality rate of AIS is 5%,⁴ while ICH is 25%.¹ However, studies indicate that 60%-74% of pediatric patients will have mild to severe residual deficits.⁴ Predictors of higher morbidity or mortality include: less than 1 year of age, altered level of consciousness or seizures at time of presentation, fevers, bilateral infarctions, or right middle cerebral artery infarctions.⁴

Recommendations:

• Create centralized emergency protocols and increase awareness and clarity across departments through simulation and modules.
• How is the pediatric stroke alert activated and by whom? What are the triggers?
• What are the initial steps of the stroke alert workflow? (e.g., individuals involved, imaging pathways)
• What communication pathways are utilized and who has decision making authority?
• Make documentation easily accessible for stroke response.
• Activate rapid response team when neurological symptoms are first observed.
• Ensure the triage screening tools encompass seizures, vomiting, and lethargy to account for symptoms often present in younger children.
• Build stroke triggers into the electronic medical record based on the patient’s age.
• Complete MRI/MRA first for suspected stroke diagnosis. Proceed to CT/CTA imaging if MRI/MRA is not available within 25 minutes.⁵
• Do not delay neuroimaging for creatine level monitoring.⁵
• Use evidence-based goals for metrics such as door to physician, door to stroke team, time from stroke alert to neural valve, time from stroke alert to imagine, etc.
• Hospitals that do not provide thrombectomy treatment should develop interhospital transfer protocols to ensure the safe and efficient transfer of patients eligible for clot removal.

Resources:

• Stroke Clinical Pathway Examples
  • Brenner Children’s Hospital, Atrium Health Wake Forest Baptist’s Stroke Pathway
  • Children’s Mercy Stroke Clinical Pathway
  • Children’s Mercy Suspected Stroke Neuroimaging Protocol
  • CHOP Clinical Pathway
  • Connecticut Children’s Stroke Clinical Pathway
  • Upstate Golisano’s Stroke Clinical Pathway
• Pediatric NIH Stroke Scale
• Pediatric Learning Solutions (PLS) Training Module: Pediatric Stroke

References:

1. Beslow, L. A. & Press, C. A. (Updated November 2025). Hemorrhagic Stroke in Children. UpToDate.
2. Fox, C. & Smith, S. E. (Updated December 2025). Ischemic Stroke in Children and Young adults: Epidemiology, Etiology, and Risk Factors. UpToDate.
3. Fox, C. & Smith, S. E. (Updated February 2026). Arterial Ischemic Stroke in Children and Adolescents: Clinical Presentation and Evaluation. UpToDate.
4. Fox, C. & Smith, S. E. (Updated September 2025). Ischemic Stroke in Children: Management and Prognosis. UpToDate.
5. Prabhakaran, S., et al. (2026). 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke, 57. doi:10.1161/STR.0000000000000513

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