Stroke in Childhood

Clinical guideline for diagnosis, management and rehabilitation

Identify children with suspected stroke

1 2 3
Identify potential stroke Pre-hospital care: Ring 999 / 111 ED: Activate acute stroke pathway

• Acute focal neurological deficit • Manage Airway

This algorithm is not wholly applicable to children with
• Speech disturbance • Administer high flow O2 if clinically indicated Sickle Cell Disease. If Sickle Cell Disease is suspected:
• Unexplained, persistent change in conscious level • Perform a capillary glucose test within 15 minutes • Discuss with paediatric haematologist
(GCS ≤ 12 OR AVPU < V) of presentation • Exchange transfusion even if initial imaging is normal
• Treat HYPOGLYCAEMIA (If capillary blood glucose
Also consider stroke in children with:
3 mmol/L give 2 ml/kg of 10% dextrose)
• Intubate if GCS < 8, AVPU = U, if there is a loss
• New onset focal seizures • Assess using FAST of airway reflexes or there is suspected / proven
• New onset severe headache • Transport to nearest ED with acute paediatric raised intracranial pressure
• Ataxia services • Administer high flow O2 and target SpO2 ≥ 92%
• Dizziness • Priority call / pre-alert ED of impending arrival • If the circulation is compromised give a 10 ml/kg
• Resolved acute focal neurological deficit of child with suspected stroke isotonic fluid bolus
• Sickle Cell Disease • Activate (locally defined) acute paediatric • Perform a capillary glucose test within 15 minutes
stroke pathway of presentation. If capillary blood glucose
• If Sickle Cell Disease is suspected, discuss with 3 mmol/L give 2 ml/kg of 10% dextrose and
Neurological assessment paediatric haematologist who should be present consider a hypoglycaemia screen
in pre-hospital care / ED
PedNIHSS definitions Scale definition

1a. Level of 0 = Alert; keenly responsive

Consciousness: 1 = Not alert, but arousable by

4 5
minor stimulation
2 = Not alert, requires repeated
stimulation to attend, or is
obtunded and requires strong Investigations Monitoring Urgent brain imaging
or painful stimulation to make
non-stereotyped movements
3 = Responds only with reflex • Venous or capillary blood gas • BP
motor or autonomic effects Perform CT / CTA < 1 Hour
• FBC, PT, APTT • Temperature
or totally unresponsive of ED admission
• Fibrinogen • SpO2
1b. LOC Questions: 0 = Answers both questions
• Urea and electrolytes • HR
Tested by asking age and correctly Record time of symptom onset
'where is XX', XX referring 1 = Answers one question • Blood glucose • RR Window for tPA = 4.5 hours
to the name of the parent
or other familiar family
correctly • Group and save • GCS
member present (> 2 years) 2 = Answers neither question Record time of admission
correctly • C-reactive protein • Assess PedNIHSS score
Window for imaging = 1 hour
• Liver function tests See ‘Neurological assessment’
1c. LOC Commands: 0 = Performs both tasks correctly
Tested by asking to open / 1 = Performs one task correctly • Blood cultures as appropriate
close the eyes and to 'show
me your nose' or 'touch
2 = Performs neither task correctly
your nose' (> 2 years)

2. Best Gaze: 0 = Normal

Horizontal eye movements
tested
1 = Partial gaze palsy
2 = Forced deviation / complete
6
gaze palsy Stroke mimic Haemorrhagic stroke Arterial ischaemic stroke
3. Visual: 0= No visual loss
Tested by visual threat 1= Partial hemianopia MRI with stroke-specific sequences Urgent discussion with neurosurgical Consider suitability for other
(2–6 years); confrontation,
finger counting (> 6 years)
2= Complete hemianopia should be performed in patients team regarding need for transfer. emergency interventions,
3= Bilateral hemianopia with suspected stroke when there such as; Thrombectomy or
(including cortical blindness) is diagnostic uncertainty. Decrompressive craniectomy.

4. Facial Palsy: 0 = Normal symmetrical

Tested by patient showing movement
teeth or raising eyebrows /

7
1 = Minor paralysis (flattened
close eyes
nasolabial fold, asymmetry
on smiling)
2 = Partial paralysis (total or near Treatment for Arterial ischaemic stroke (AIS)
total paralysis of lower face)
3 = Complete paralysis of one or
both sides Aspirin
In children presenting with AIS Thrombolysis, the use of tPA...
5 & 6. Motor Arm 5a. Left Arm, 5b. Right Arm • 5mg/kg ≤ 1
may be considered if 2–8 years and could be considered if ≥ 8 years
and Leg: 0= No drift for full 10 seconds hour (Unless
Tested by patient extending 1= Drift ≤ 10 seconds CI, e.g.
arms 90 degrees (if sitting)
or 45 degrees (if supine), 2= Some effort against gravity parenchymal IF ALL OF THE FOLLOWING ARE TRUE:
and the leg 30 degrees 3= No effort against gravity haemorrhage)
• PedNIHSS ≥ 4 and ≤ 24
4= No movement
• Delay for
5= Amputation • tPA can be administered ≤ 4.5 hours of symptom onset
24 hours in
context of • CT has excluded intracranial haemorrhage
6a. Left Leg, 6b. Right Leg
thrombolysis • CTA demonstrates normal brain parenchyma or minimal early ischaemic change
0= No drift for full 5 seconds
1= Drift 5 seconds • CTA demonstrates partial / complete occlusion of the intracranial artery corresponding
2= Some effort against gravity to clinical / radiological deficit
3= No effort against gravity
OR
4= No movement
5= Amputation • MRI and MRA showing evidence of acute ischaemia on diffusion weighted imaging
+ partial / complete occlusion of the intracranial artery corresponding to clinical /
7. Limb Ataxia: 0 = Absent
radiological deficit
Tested for by reaching 1 = Present in one limb
for a toy / kicking a toy (< 5
years); finger-nose-finger /
2 = Present in two limbs PROVIDING THAT THERE ARE NO CONTRAINDICATIONS
heel-shin tests (> 5 years)

8. Sensory: 0 = Normal; no sensory loss

Observe behavioural 1 = Mild to moderate sensory loss
response to pin prick
2 = Severe to total sensory loss aPTT=Activated partial thromboplastin time; AVPA=Alert, Voice, Pain, Unresponsive; CI=Contra-indication; CT=Computerised
tomography; CTA=Computerised tomography angiography; ED=Emergency Department; FAST=Face, Arms, Speech Time;
FBC=Full blood count; GCS=Glasgow Coma Scale; HR=Heart rate; LOC=Level of consciousness; MRA=Magnetic resonance
9. Best Language: 0= Normal angiogram; MRI=Magnetic resonance imaging; AIS=Arterial ischaemic stroke; O2=Oxygen; PedNIHSS=Paediatric National Institute
Tested by observing 1= Mild to moderate aphasia of Health Stroke Scale; PT=Prothrombin time; RR=Respiratory rate; SpO2=Oxygen saturation; tPA=Tissue plasminogen activator.
speech and comprehension
(2–6 years); describe
2= Severe aphasia
picture (> 6 years) 3= Mute, global aphasia Produced in line with the full RCPCH clinical guideline.
For further details on all recommendations, visit: www.rcpch.ac.uk/stroke-guideline