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Flowcharts

  1. Paediatric stroke presentation flowchart [PDF 765.43 KB] - 1 page
  2. Paediatric stroke investigation flowchart [PDF 806.35 KB] - 1 page
  3. Ischaemic stroke positive flowchart [PDF 741.67 KB] - 1 page
  4. Haemorrhagic stroke positive flowchart [PDF 724.68 KB] - 1 page
  5. Haemorrhagic stroke inconclusive flowchart [PDF 750.67 KB] - 1 page
  6. TIA pathway flowchart [PDF 772.76 KB] - 1 page
  7. Sickle cell flowchart [PDF 794.22 KB] - 1 page

Clinical Pathway

  1. QCH Specific: Clinical Pathway: Emergency Management of Acute Suspected Paediatric Acute Arterial Ischaemic Stroke [PDF 331.63 KB] - 4 pages

PEDNIHSS

  1. Paediatric NIH Stroke Scale (PedNIHSS) form - 4 pages
  2. Paediatric NIH Stroke Scale (NIHSS) (mdcalc.com)

Neuroprotection

  1. CHQ-NSS-51048 Neuroprotection Checklist [PDF 218.32 KB] - 2 pages
  2. Neuroprotective Care - Detailed information for the acute management of haemorrhagic or ischaemic stroke [PDF 278.95 KB] - 4 pages

Radiology

  1. Paediatric Stroke – QCH MR protocol [PDF 156.96 KB] - 1 page

Thrombolysis for Paediatric Ischaemic Stroke

  1. Checklist Prior to Administration of Alteplase for Paediatric Ischaemic Stroke - 2 pages
  2. Paediatric Ischaemic Stroke Alteplase Eligibility and Contraindications - 2 pages
  3. Specific Consent for Thrombectomy: Endovascular Thrombectomy and/or Thrombolysis for Acute Ischaemic Stroke Consent - 6 pages
  4. Paediatric Stroke – Alteplase Administration Guideline for Paediatric Arterial Ischaemic Stroke [PDF 1058.74 KB] - 12 pages
  5. Paediatric Stroke – The 72hrs post Alteplase [PDF 236.18 KB] - 12 pages

Key points

  • Stroke (Haemorrhagic/Ischaemic) is a medical emergency: early recognition, neuroprotective care, stroke extension/recurrence prevention, hyperacute treatments and neurosurgical intervention can make a difference to long term disability and death.1
  • Seizures are a common presentation for both ischaemic and haemorrhagic childhood stroke. They occur in one-third to half of children suffering stroke.2
  • Paediatric stroke can occur at any age and the incidence is greater than paediatric brain tumour.3, 4
  • Early paediatric critical care and neurology or neurosurgical involvement is essential.5
  • Ischaemic stroke: Currently in Australia there is significant delays to recognition and management of children who suffer ischaemic stroke.  The streamlined services available to adults are not broadly available for children. Children continue to have diagnostic delays that extend beyond 24hrs making them ineligible for acute treatment options. In hospital delays constitute the largest barrier to care.6
  • Transient Ischaemic Attacks (TIA): Children like adults can experience transient ischaemic attacks (TIA). As in adults, TIA symptoms may herald stroke – the rate of progression is concordant with the rate in adults. Four percent of children who present with TIA will progress to stroke during the acute admission. It is important to consider this diagnosis in children who present with symptoms/signs consistent with stroke where resolution has occurred. The diagnosis of TIA is made primarily on history. A careful history can usually differentiate TIA from migraine, focal seizures and other causes of transient focal neurological symptoms.7

Purpose

This document provides guidance for all staff in Queensland involved in the care and management of children aged 29 days to <18 years of age presenting to an Emergency Department (ED) with suspected or proven childhood ischaemic stroke and non-traumatic intracranial haemorrhagic stroke. It also provides guidance for the care and management of children presenting to an ED with symptoms of transient ischaemic attack (TIA)

Young people ≥16yrs who are not currently managed within a Queensland Health paediatric setting should be managed by an adult stroke service. In this instance, the paediatric neurologists are available for consultation for young people ≥16yrs to <18years if the adult stroke service requires paediatric assistance.

This document is not inclusive of adult stroke, cerebral sinus venous thrombosis, Moya-Moya disease, spinal stroke, perinatal stroke (unless in congenital heart disease patients), and traumatic intracranial haemorrhage.

The treatment of stroke in Sickle Cell Disease is also urgent and requires specific urgent management. This guideline provides for their inclusion in the flowcharts to assist with the URGENT identification of children with Sickle Cell Disease related stroke, and links to CHQ-GDL-70044 - Sickle Cell Crisis – Emergency Management in Children [PDF 368.57 KB]. Children with Sickle Cell Disease can suffer both haemorrhagic and ischaemic stroke. Management of stroke in Sickle Cell Disease requires URGENT exchange transfusion. (Thrombolysis and endovascular therapies are usually not indicated.)

This guideline has been developed by senior Paediatric ED clinicians, Paediatric Neurologists, Paediatric Intensive Care Specialists, Paediatric Radiologists/Radiographers, and Paediatricians across the state with specialist input from the following paediatric subspecialities: Haematology, Anaesthesia, Neurosurgery, Cardiology, Cardiac Surgery, Pharmacy, and Pathology. RSQ and QAS have also provided specialist input.

It has been endorsed for use across Queensland by the Statewide Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel (QEDSAP) and the Healthcare Improvement Unit, Clinical Excellence Queensland. Additionally, it has also been endorsed for use by the Queensland Stroke Clinical Network.

Introduction

Childhood stroke falls within the top 10 cause of childhood death. This disease places long-term adverse individual, functional and psychosocial impacts as well as economic consequences on the healthcare system, families and the community.3

Child-specific diagnostic, investigation and management protocols are crucial for accurate and timely diagnosis so that treatments are accessible. Adult pathways should not be used. The diagnosis of stroke is more complex in children due to the higher frequency of stroke mimics, variability in age of presentation, diversity of causes (which differ from adult stroke) and incidence of associated complex co-morbid conditions.2

There are two broad categories of paediatric stroke, Acute Ischaemic Stroke and Haemorrhagic Stroke. Haemorrhagic stroke encompasses Intracerebral Haemorrhage (ICH) and Sub Arachnoid Haemorrhage (SAH).

Table 1:  Demographic Data
Paediatric Acute Ischaemic Stroke Paediatric Haemorrhagic Stroke – Intracerebral Haemorrhage (ICH) and Subarachnoid Haemorrhage (SAH)
Incidence – children >1 month of age 1.2-8 per 100 000 per year.  ~1.7 per 100 000 per year
Mortality 5-10% 10-20%
Long term neurological impairment >50% >50%
Recurrent strokes 10-20%  
Major Risk Factors

NOTE:  50% of strokes  occur when children have been previously well.

Cardiac disease
Head and neck trauma
Sickle cell disease
Haematological disorders
Arteriopathies e.g.

  • focal cerebral arteriopathy
  • cervico-cephalic arterial dissection

Vascular malformations – 40-90% of ICH

  • arteriovenous malformations (AVMs)
  • intracranial aneurysms
  • cerebral cavernous malformations

Sickle cell disease
Tumours
Cardiac disease
Inherited or acquired (drug-induced) bleeding disorders

Triage

As per the Emergency Triage Education Kit (ETEK), children with signs of potential stroke (ischaemic or haemorrhagic) should be triaged a minimum Australian Triage Scale (ATS) of 2, with a recommended maximum time to medical assessment of 10 minutes.

Children with a potential diagnosis of transient ischaemic attack will have experienced sudden onset of any of the below signs and symptoms of stroke, but these will have COMPLETELY resolved. If the triage nurse is confident that there has been complete resolution, then the child may be triaged an ATS of 3 (medical assessment within 30 minutes). If there is ANY doubt, the child should be triaged a minimum ATS of 2.

Centres that have specific paediatric code stroke have instituted recognition tools at the point of triage. These may be electronic, policy or education based. Please see CHQ-WI- 00738 Triage of Children with suspected Acute Arterial Ischaemic Stroke [PDF 599.42 KB].

Assessment

A rapid assessment (history and examination) is performed by the most senior clinician available to establish if the presenting symptoms in conjunction with the history are suggestive of suspected stroke (ischaemic or haemorrhagic).

It should be noted that presence of unequal pupils can be one of the earliest signs of carotid artery dissection or posterior circulation haemorrhage (affecting brainstem, cerebellum, and thalamus). Carotid artery dissection may also be accompanied by neck pain or a Horner’s syndrome (characterised by eyelid ptosis and miosis, a constricted pupil).

Table 2: Symptoms and Signs of Stroke (Ischaemic and Haemorrhagic) SUDDEN or STUTTERING onset of any of below symptoms:
Focal Weakness
  • Hemiplegia
  • Weakness of a limb or part of a limb
  • Facial droop

Vision Disturbance

(excluding intrinsic eye condition)
  • Visual field defects – most common visual sign of stroke
  • Double vision
  • Loss of vision
Pupil Disturbance
  • Pupillary disturbance/unequal pupils (new onset)
Speech/Language Disturbance
  • Slurred speech
  • Incomprehensible speech
  • Unable to speak
Seizures
  • New onset seizures with associated neurological signs
Headache
  • Headache with associated neurological signs
  • Thunderclap headache – severe headache of sudden onset where the time to maximal symptoms occurs over seconds to minutes
Limb incoordination or ataxia
  • Unsteady gait
  • Increased frequent falling
  • Upper limb incoordination
Neglect
  • Child appears not to notice/respond to one side of their body or vision or the room
Altered conscious state
  • Use AVPU scoring
Raised intracranial pressure (ICP)

Features vary with degree of severity:
Mild to moderate

  • Severe, persistent headache associated with vomiting
  • Altered conscious state

Severe – associated with brain herniation

  • Severe altered conscious state - unresponsive
  • Cushing’s triad – bradycardia, hypertension and irregular respirations
  • Widened pulse pressure
  • Restricted eye movements associated with a 6th nerve palsy
  • Unequal pupils, dilated or fixed, non-reactive pupils
  • Decorticate or decerebrate posturing
Table 3: Consider TIA when
Neurological symptoms (as above) have COMPLETELY resolved at presentation

Recognition difficulties - paediatric posterior circulation arterial ischaemic stroke

Paediatric Posterior Circulation Arterial Ischaemic Stroke (PCAIS) accounts for approximately 20% of paediatric stroke.6,8

The posterior circulation is responsible for blood flow to the cerebellum, brain stem, midbrain, posterior cerebral cortex, and most of the thalamus.

PCAIS may present with symptomatology indicative of classical stroke symptoms such as hemi-motor and/or hemi-sensory symptoms. However, it may also present with loss of consciousness, or isolated focal neurology e.g. visual field defects and/or ataxia/incoordination. Thirty-eight percent present with non-specific symptoms including nausea and vomiting, dizziness and headache, symptoms that are most often associated with benign and more common disorders in the paediatric population.6,8

Further information on posterior circulation stroke is available on the Clinical Signs associated with Vascular Territories guideline [PDF 162.31 KB].

It is recognised in the adult literature that posterior stroke has an expected miss/late diagnosis rate of 2-3 times that seen for anterior stroke. PCAIS is also associated with a lower average stroke severity score on the Paediatric National Institutes of Health Stroke Scale/Score (PEDNIHSS). A high index of suspicion needs to be maintained to successfully detect PCAIS given these recognised difficulties.6,8

The risk of stroke recurrence in Paediatric PCAIS is 19% compared to 4% for anterior circulation arterial ischaemic stroke, a feature that makes early detection important.6,9

History

Timing and onset of symptoms in stroke is usually very sudden. Thus, a clear description of the onset and progression of symptoms is important. Recurrent and stuttering symptoms are also important to delineate. History taking with consideration of the symptoms and signs of stroke (see Table 2) should be included.

It is important to obtain specific details regarding the date and time of the onset of the acute neurological deficit. If this is unknown, then document date and time the patient was last seen well/at baseline. If the patient wakes with symptoms, then document time of sleep onset and time of waking.

Additionally, precipitating factors should be specifically evaluated.

Table 4: Precipitating factors
Ischaemic stroke Haemorrhagic stroke
  • Recent trauma may increase risk for vascular dissection.
    • Major trauma (e.g. motor vehicle/bike accident, bicycle, scooter including e-scooter, pedestrian vs car)
    • Chiropractic manipulation
    • Contact sport (e.g. rugby, trampoline etc)
    • Hanging or other direct neck trauma
    • Palatal/pharynx injury
  • Congenital or acquired cardiac disease
  • Recent viral infection (particularly Varicella and HSV)
    • Risk of focal cerebral arteriopathy
  • Current severe bacterial infection
    • Risk of coagulopathy, septic emboli or vasculopathy
  • Malignancy
    • Risk of coagulopathy
  • Haematological disease
    • Sickle cell disease
  • Prothrombotic medications
  • Vascular malformations
    • Arteriovenous malformations (AVM)
    • Arteriovenous fistulae
    • Cavernous Malformations (CM)
    • Cerebral Aneurysms
    • Arteriopathies (e.g. Moya Moya)
  • Haematological Disorders
    • Thrombocytopaenia (e.g. ITP)
    • Congenital coagulopathy (e.g. Haemophilia, Von Willebrand Disease, factor deficiencies, thrombasthenia)
    • Acquired coagulopathy (e.g. Snake bite, anticoagulants, sodium valproate)
    • Haemoglobinopathies (e.g. Sickle cell disease)
  • Brain Neoplasms
  • Toxins – sympathomimetic drugs particularly amphetamines and cocaine may increase the risk of haemorrhagic stroke by causing sudden severe rises in blood pressure.
  • Unknown – 10%

Sickle cell disease

It is important to identify children with symptoms and signs of stroke who also have Sickle Cell Disease. Children from Sickle Cell Disease endemic areas (Africa, Middle east etc) may present to hospital without a diagnosis and a high index of suspicion for the condition needs to be maintained and urgent blood film review and consultation with Clinical Haematology for urgent testing should be considered. Management of stroke in Sickle Cell Disease requires URGENT exchange transfusion. (Thrombolysis and endovascular therapies are usually not indicated.)

Please see CHQ-GDL-70044 - Sickle Cell Crisis – Emergency Management in Children [PDF 368.57 KB]

Please see Flowchart for Stroke in Children with Sickle Cell Disease [PDF 794.22 KB]

Examination

ABC - Airway, Breathing, and Circulation takes priority.

D - Assessment of GCS and pupillary response with associated management of abnormalities.

Examination should be guided by the presenting features especially if there is concomitant illness.

See Clinical Signs associated with Vascular Territories [PDF 162.31 KB] for clinical signs of anterior and posterior circulation strokes.

Neurological assessment

PEDNIHSS is a validated neurological assessment tool for ischaemic stroke severity in children 2-18yrs and is critical to decision making around candidacy for reperfusion therapy.

It must be completed BEFORE reperfusion treatment decisions are made.

Where there is possibility of ischaemic stroke perform PEDNIHSS and discuss with Paediatric Neurologist.

Please see:

As the PEDNIHSS is not validated for children <2yrs, discuss neurological examination findings of children <2yrs directly with the Paediatric Neurologist.

The on call Paediatric Neurologist can assist medical staff if there are issues with PEDNIHSS familiarity.

Inexperience with performing or grading this assessment should not result in delays.

Weight

An accurate weight is essential in the calculation of thrombolytic therapy. An estimated weight must not be used.

Eye examination

Where the presenting complaint is primarily related to visual disturbance, the eyes should be examined for a potential intrinsic ophthalmological cause.

Cardiac examination

A cardiac examination should be performed. Consider potential causes (ischaemic/haemorrhagic):

  • Endocarditis
  • Murmur suggesting right to left shunt
  • Hypertension

Additional examination for suspected haemorrhagic stroke

Bleeding disorder - where haemorrhagic stroke is thought probable, evidence of clinical signs of:

  • Bleeding diathesis – unusual bleeding or bruising in skin, mucosa, gums
  • Snake bite – presence of two puncture wounds, usually on a limb

Note that there are common stroke mimics which present with altered level of consciousness and/or focal neurological signs which need to be considered in the overall patient assessment. These include:

Table 5: Differential diagnoses of the presenting symptoms and signs of stroke
  • Migraine
  • Seizures with Todd's Paresis
  • Bell's Palsy
  • Functional disorders
  • Cerebellitis
  • Meningoencephalitis
  • Acute Disseminated Encephalomyelitis (ADEM)
  • Space occupying lesions
    • Benign and malignant tumours
    • Infections

Vascular territories

Please see Clinical Signs associated with Vascular Territories [PDF 162.31 KB] in stroke.

Initial procedures and investigations – haemorrhagic and ischaemic stroke

Table 6: Differentiation of stroke types

Consider haemorrhagic over ischaemic stroke when

Sudden changes:

  • New onset unequal pupil
  • Thunderclap headache (a severe headache that reaches maximal intensity over seconds to minutes)

Evidence of mild to moderate raised intracranial pressure:

  • Severe, persistent headache associated with vomiting
  • Altered conscious state

Evidence of severe raised intracranial pressure with brain herniation:

  • Severe altered conscious state - unresponsive
  • Cushing’s triad – bradycardia, hypertension and irregular respirations
  • Widened pulse pressure
  • Decerebrate or decorticate posturing
  • Unequal pupils, dilated or fixed, non-reactive pupil/s
  • Restricted eye movements - sixth nerve palsy

Immediate actions high suspicion of haemorrhagic stroke

Where there is high suspicion of haemorrhagic stroke, no consultation is required prior to imaging. ED clinicians should proceed immediately with IV access (cubital fossa, minimum 22 Gauge, no extension tubing, for contrast), laboratory/radiological investigations and neuroprotective care, whilst simultaneously contacting the on-call neurosurgical service (via RSQ if required).

Consultation requirement prior to ischaemic stroke investigations

It is not recommended that investigation and imaging proceed for paediatric ischaemic stroke until a discussion with the Paediatric Neurology Consultant has occurred and advice has been given to proceed. Paediatric Neurology consultation improves pre-test probability and reduces requirement for URGENT neuroimaging and investigation. It also ensures that Paediatric Neurology staff are ready and available to receive transmitted images.

The Consultant Paediatric Neurologist should be contacted prior to imaging (24hrs/day). For immediate critical care clinical support call RSQ (1300 799 127). For imaging decision advice call the Paediatric Neurologist via QCH switch (07) 3068 1111. Note Townsville University Hospital calls the TUH/QCH Paediatric Neurologist as per the TUH internal roster.

Consultation requirement for children with sickle cell disease presenting with signs and symptoms of stroke

It is recommended that the QCH Haematology Consultant is contacted urgently when a child with known Sickle Cell Disease presents with stuttering, persistent or fluctuating evidence of a neurological deficit.

The Consultant Paediatric Haematologist should be contacted 24hrs/day via QCH switch (07) 3068 1111. For immediate critical care clinical support call RSQ (1300 799 127).

Intravenous (IV) access and laboratory investigations

Obtain IV access. Cubital fossa access with a minimum 22G (blue) is preferred for contrast. Do not wait for anaesthetic cream. Note that two peripheral IVs are required before lysis can be administered.

Phone pathology to advise the tests for this patient are URGENT:

  1. Full blood count (FBC)
  2. Chem 20 (general biochemistry profile) - includes glucose, electrolytes, renal function and liver function tests
  3. Coagulation profile
  4. Clottable fibrinogen (in some centres this is not included in the coagulation profile and needs to be ordered separately)
  5. Group and save

Neuroprotective Care

Neuroprotection must be offered whilst urgent neuroimaging is facilitated.

Further details are outlined in:

Neuroimaging

Neuroimaging is essential for the diagnosis of childhood stroke and to differentiate ischaemic and haemorrhagic stroke from stroke mimics.

Alert

Non-contrast CT Head has poor sensitivity (as low as 19%) for detection of Acute Arterial Ischaemic Stroke in children and should NOT be used for this purpose.

The choice of radiologic study depends on the available imaging resources and the clinical features of the case. Initial suspicions of haemorrhagic stroke will only impact imaging decisions in centres with immediate access to both MRI and CT.

Table 7: Site dependent neuroimaging
Site without access to CT or MRI

For imaging decision advice about possible ischaemic stroke call the Paediatric Neurologist via QCH switch (07) 3068 1111.

For immediate critical care clinical support call RSQ (1300 799 127).

Site with access to CT (no access/no immediate access to MRI)

Where there is immediate high suspicion of haemorrhagic stroke clinicians should pursue CT head (+/- CTA) looking for evidence of cerebral haemorrhage. See Table 6 - Differentiation of Stroke Types
For imaging decision advice about possible ischaemic stroke call:

  • Paediatric Neurologist via QCH switch (07) 3068 1111
  • Townsville University Hospital calls the TUH/QCH Paediatric Neurologist as per the TUH internal roster

CT/CTA head
Additional Tests ONLY if advised by paediatric neurologist and/or interventional neuroradiologist

  • CT/CTA neck
  • CT perfusion
  • Children might require low dose paediatric specific CT perfusion protocols.
  • Perfusion imaging should only ever be considered if stroke is demonstrated on MRI (or occlusion is demonstrated on CTA), and the perfusion imaging is required to assist with reperfusion decisions.
  • Perfusion imaging might be required to extend time windows for treatment.

Children with ongoing neurology but negative CT/CTA should be discussed with the paediatric neurologist - MRI still likely required (retrieval/transfer).

For immediate critical care clinical support call RSQ (1300 799 127).

Site with immediate access to CT and MRI

Where there is immediate high suspicion of haemorrhagic stroke clinicians should pursue CT head (+/- CTA) looking for evidence of cerebral haemorrhage. See Table 6 - Differentiation of Stroke Types. If the results are negative consider progress to ischaemic investigation pathway.

For imaging decision advice about possible ischaemic stroke call the

  • Paediatric Neurologist via QCH switch (07) 3068 1111
  • Townsville University Hospital calls the TUH/QCH Paediatric Neurologist as per the TUH internal roster

Where there is suspicion of ischaemic stroke clinicians should consult the Paediatric Neurologist and then if instructed pursue MRI/MRA brain as the first investigation where possible. MRA neck vessels and MRI perfusion might be indicated.

If immediate critical care clinical support is required and not available on site call RSQ (1300 799 127).

Protocol for neuroimaging: MRI/MRA brain

Please see: QCH Protocol for MR Brain with Angiogram for Presumed Paediatric Acute Arterial Ischaemic Stroke [PDF 156.96 KB].

Specific neuroimaging issues with sickle cell disease

Note children with Sickle Cell Disease cannot have CT contrast.

At QCH the Presumed Paediatric Acute Arterial Ischaemic Stroke MRI protocol is used for children with Sickle Cell Disease who have acute neurological signs and symptoms: QCH Protocol for MR Brain with Angiogram for Presumed Paediatric Acute Arterial Ischaemic Stroke [PDF 156.96 KB]

Radiology workflow for neuroimaging performed at sites external to QCH

Please see: Radiology Workflow for Neuroimaging performed at sites external to QCH [PDF 420.87 KB].

Reasoning behind choice of imaging modality in ischaemic stroke

MRI is the preferred modality of imaging in children with symptoms of suspected ischaemic stroke because of the high sensitivity for diagnosis. MRI diffusion weighted imaging changes of ischaemic stroke occur very rapidly after onset of symptoms (within minutes) whereas hypodensity on CT takes up to 24hrs to be seen.

Neuroimaging and reperfusion decisions

Both MR angiogram and CT angiogram are adequate tests for diagnosis of a large vessel cerebral arterial occlusion. If no partial or complete arterial occlusion is seen on MR or CT angiogram, then a child will not be a candidate for reperfusion treatments based on current international guidelines and practice.

Where a child is a candidate for reperfusion treatment based on the MR or CT angiogram results, further information regarding the size/volume of the ischaemic stroke and penumbra may be required to be able to proceed with reperfusion treatments. Perfusion imaging (MR or CT) should only ever be performed if stroke is demonstrated on MRI (or occlusion is demonstrated on CTA) and there is potential for reperfusion therapy.

CT and MR perfusion in children

CT and MR perfusion is performed on a case-by-case basis in children. Expert advice is required prior to performing perfusion imaging. Perfusion imaging is only performed if stroke is demonstrated and/or there is arterial occlusion, and perfusion imaging is deemed helpful for consideration of extended time window for reperfusion therapy. Clinical trial data of perfusion imaging in paediatric patients is lacking, and optimal perfusion thresholds are yet to be determined. A cautious approach to utilising perfusion imaging for clinical decision making in children is therefore recommended.

The radiation dose associated with CT perfusion in children is high and children might require paediatric specific protocols. Decisions to use CT perfusion must determine that benefit outweighs risk.

In adults, CT perfusion is commonly used to determine the size/volume of the ischaemic stroke and penumbra for reperfusion therapy decisions, particularly where there is a need to assess for extended time frames for treatment.

Caution with CT/CTA

If CT/CTA is initially performed and no ischaemic stroke is identified, this DOES NOT exclude stroke.

The false reassurance associated with negative CT/CTA causes delay. Although the negative CT/CTA can be used to determine eligibility for reperfusion therapies, it cannot be used to determine need for ongoing stroke care i.e. antithrombotic, neuroprotective care and monitoring for stroke extension. Negative CT/CTA has been shown to cause delay in definitive MRI. MRI should be pursued where there is ongoing suspicion of ischaemic stroke on clinical assessment despite negative CT/CTA.

Benefits of MR brain with angiogram as first line investigation

Where MRI is used as a first line investigation diagnostic delays are markedly reduced.

Evidence behind choice of imaging modality in subarachnoid haemorrhage

A CT Head within 6hrs of onset, together with a neuroradiologist report, has a high sensitivity and is sufficient to rule out subarachnoid haemorrhage (SAH). However, in healthcare settings where neuroradiology expertise is unavailable, caution should be exercised when translating the diagnostic accuracy of CT Head.

After 6 hours, CT sensitivity drops off and subarachnoid haemorrhage (SAH) cannot be ruled out. For cases where CT Head is negative, an MRI is the preferred modality with high sensitivity.

If MRI is not available, a lumbar puncture looking for xanthochromia after 12 hours should be considered to exclude SAH. This must be performed in context of clinical scenario, contraindications and patient safety. Sedation/analgesia should be used to avoid distress, hypertension and risk of rupture of an aneurysm.

Table 8: Resources to facilitate “Time is Brain” investigation priorities for Acute Ischaemic Stroke – Immediate Response Protocols, Clinical Pathways and Paediatric Neurologist Support

Immediate response protocols
There is a growing body of evidence to show that implementation of a standardised immediate response protocol in Emergency Departments reduces delay in diagnosis and improves access to available reperfusion therapies and management for paediatric acute ischaemic stroke patients. Thus, reducing morbidity and mortality.

For External Facilities: Checklist for establishing a Local Paediatric Immediate Response Protocol for Paediatric Acute Ischaemic Stroke [PDF 217.92 KB]

Sites may choose to develop their own Paediatric Code Stroke Activation document using the below QCH Specific documents as a guide.

QCH Specific: CHQ-PROC-00737 Paediatric Code Stroke Activation - Activation of the Code Stroke Call at QCH
QCH Specific: QCH Code Stroke Activation [PDF 472.15 KB]

Clinical pathways
These are standardised, evidence-based management plans that outline a sequence of clinical interventions. Clinical pathways need to be site specific to accommodate for local resourcing. Sites may choose to develop their own clinical pathway using the below QCH Specific Clinical Pathway as a guide.

QCH Specific: Clinical Pathway: Emergency Management of Acute Suspected Paediatric Acute Arterial Ischaemic Stroke [PDF 331.63 KB]

Paediatric neurologist support
In addition to decision support to pursue urgent investigation and neuroimaging, this includes:

  • Patient review (in person, or via phone)
  • Neurologist will discuss imaging with radiologist/interventional neuroradiologist
  • Decision to treat and consent
    • reperfusion therapies in paediatrics are based on consensus guidelines and adult evidence thus decision to treat and consent should lie primarily with the Paediatric Neurologist
  • Ongoing clinical support post lysis
  • Ongoing clinical support for management of ischaemic stroke

Management – Acute arterial ischaemic stroke

Consultation - children with cardiac diagnoses

Cardiology and Cardiac Surgery - Children who have undergone cardiac surgery who present with Acute Arterial Ischaemic Stroke need involvement of their treating teams (Cardiology and Cardiac Surgery) in all decisions regarding acute arterial stroke management.

Please see Cardiology Consultation and Investigations [PDF 121.9 KB]

Neuroprotective care

Further details are outlined in:

Antithrombotic therapy

In children there are currently no randomised controlled trials published on the efficacy of anticoagulation or antiplatelet therapy in children with Acute Arterial Ischaemic Stroke. Despite the absence of controlled trials, there is a body of evidence supporting the efficacy and safety of using anticoagulation and antiplatelet therapy in children with stroke and multiple international guidelines provide recommendations for antithrombotic therapy. The goal for antithrombotic therapy is to reduce the risk of stroke extension or recurrence.

Advice should be sought from the Paediatric Neurologist about treatment with these agents.

CAUTION: For children who receive thrombolysis with alteplase: There should not be any administration of any anticoagulant or antiplatelet agent until 24hrs after the Alteplase (tPA) infusion i.e. VKA/warfarin, LMWH, DOACs (direct oral anticoagulant), unfractionated heparin or anti-platelet agents (including oral aspirin).

Reperfusion therapies

Treatment with intravenous Alteplase and endovascular therapies have been proven to be effective in multiple large randomised controlled trials in adults.

Children traditionally have not been diagnosed in time to be offered treatment. There is an absence of trials or high-quality evidence in children. Due to the absence of randomised trial evidence for benefit, thrombolytic agents are not approved by the Therapeutic Goods Administration for use in Australian children with Acute Arterial Ischaemic Stroke.

However, there are a growing number of international publications reporting use of these interventions. The Australian National Guideline “Diagnosis and Acute Management of Childhood Stroke”6 and the AHA guideline “Management of Stroke in Neonates and Children”10 provide consensus guidance for thrombolysis with Alteplase and endovascular therapies in children. These guidelines have been extrapolated from adult evidence. This means that benefit over harm for children cannot be accurately assessed.

Where administration of Alteplase, or endovascular therapy, is being considered for children with Acute Arterial Ischaemic Stroke, an experienced team of paediatric neurologists, radiologists, haematologists, and if required interventional neuroradiologist and paediatric critical care specialists should be consulted. Professionals should take a cautious approach appreciating the lower level of evidence for safety and efficacy in children.

Endovascular therapy

Endovascular Therapy is considered in children with Acute Arterial Ischaemic Stroke and endovascular therapy might be the preferred reperfusion treatment modality in some children with Acute Arterial Ischaemic Stroke (e.g. proximal large vessel occlusion). Eligibility criteria for children are based on adult eligibility criteria however there are important safety considerations that are specific to children. This includes consideration of the high rate of arteriopathy and technical difficulties due to the size of the child. Focal cerebral arteriopathy is one of the most common causes of paediatric acute arterial ischaemic stroke and the presence of this condition can be difficult to determine on initial MR or CT angiogram. Focal cerebral arteriopathy is considered a relative contraindication to endovascular therapy with data suggesting a higher risk of complications. Any decision around endovascular therapy in a child should be made on a case-by-case basis with expert advice from a Paediatric Neurologist and an Interventional Neuroradiologist experienced in paediatric stroke care.

Thrombolysis with alteplase

Alteplase is considered in children with Acute Arterial Ischaemic Stroke. The timeframes are extrapolated from adult literature. Alteplase has proven effectiveness in adults with stroke when it is given <4.5 hours following stroke onset. An identical timeframe is used for children. In adults, there is also provision for extended time window Alteplase, however this option is not currently practiced in paediatric stroke care.

Please see the following for further information:

Paediatric acute arterial ischaemic stroke complications

Complications can occur with or without treatment.

Neurological deterioration, clinical signs of raised intracranial pressure or abnormalities in vital signs in a patient with acute arterial ischaemic stroke may be indicative of a complication requiring immediate medical and/or neurosurgical review.

  • stroke extension
  • recurrent stroke
  • haemorrhagic stroke conversion
  • malignant cerebral oedema/malignant middle cerebral artery infarction.

Malignant cerebral oedema

Raised Intracranial Pressure (ICP) due to malignant cerebral oedema surrounding the stroke can occur in paediatric patients with Acute Arterial Ischaemic Stroke and is a major contributor to morbidity and mortality in paediatric stroke.

The highest risk period is in the first few hours to days after Acute Arterial Ischaemic Stroke. Malignant oedema usually develops within the first 72hrs following an Acute Arterial Ischaemic Stroke but can rarely occur later. Important indicators include deteriorating level of consciousness, unilateral pupillary dilation, abnormal eye movements, worsening of existing neurological deficit, development of other focal neurological deficits and a change in vital signs (developing hypertension or bradycardia). Emergency notification and assessment by the paediatric intensivist, neurosurgeon and neurologist is required with any deterioration in neurological status.

Decompressive craniectomy in paediatric acute arterial ischaemic stroke

Timely intervention (decompressive hemicraniectomy and supportive medical management) may be lifesaving and may reduce morbidity. Emergency notification and involvement of neurology, neurosurgery and paediatric intensive care is required with any deterioration in neurological status. Neuroprotective care should continue while organising definitive surgical management.

Further details are outlined in:

Management – Stroke in sickle cell disease

Please see CHQ-GDL-70044 - Sickle Cell Crisis – Emergency Management in Children [PDF 368.57 KB]

Management - Haemorrhagic stroke

Neuroprotective care

Further details are outlined in:

Definitive neurosurgical therapies

Once a haemorrhagic stroke has been confirmed, the catchment on-call Paediatric Neurosurgeon should be notified immediately (via RSQ if required). Delay to definitive operative therapies may be detrimental.

Possible options for definitive treatment will depend on multiple factors including the location, size and timing of the bleed.

Possible options will include the following:

  • Extra ventricular drain (EVD)
  • Surgical evacuation
  • Surgical resection, radiosurgery and/or embolisation for AVMs
  • Surgical clipping or endovascular coiling for aneurysms
  • Medical and endovascular management of cerebral vasospasm

Reversal of coagulopathy

Any reversible risk factors resulting in bleeding should be sought and treated. Acquired coagulopathies such as snake bites or supratherapeutic ingestions of anticoagulants should be discussed with poisons and haematology. Congenital coagulopathies and thrombocytopaenia’s should be discussed with haematology. Where possible proposed treatments and targets for INR, PT/APTT, platelets and fibrinogen should be discussed with the treating neurosurgeon prior to commencement of therapy.

Transient Ischaemic Attack

History and Examination

A transient ischaemic attack (TIA) should be considered for children presenting with acute neurological symptoms and signs that have now resolved. Children who have had a TIA are at risk of TIA recurrence or acute ischaemic stroke. If TIA is suspected, further investigation and treatment may be warranted.

If TIA is suspected and neurological symptoms and signs have completely resolved, time can be taken to complete a full history and examination. See flowchart for details of essential history elements.

Please see TIA Pathway Flowchart [PDF 772.76 KB]

Please see Clinical Signs associated with Vascular Territories [PDF 162.31 KB]

Alert

If the symptoms and signs have not completely resolved or recur after prior resolution, the code stroke pathway should be used.

Consultation

Neurology

When a TIA is suspected as the most likely diagnosis, all children should be discussed with the Paediatric Neurologist on call prior to discharge home. Overnight, consultation can be delayed to the morning if the symptoms are completely resolved and have not recurred. Consultation with neurology should occur after the history, examination and initial investigations (e.g. bloods, ECG) are complete (unless local pathology services are unavailable).

The paediatric neurologist will provide guidance regarding the need for MRI neuroimaging and the required urgency.

Ophthalmology

Any child presenting with visual disturbance which may be attributable to a TIA should be discussed with the ophthalmology team and undergo formal ophthalmological examination/follow-up as indicated.

Cardiology and oncology

For children who are known to cardiology or oncology, they should be discussed with their respective treating teams.

Please see Cardiology Consultation and Investigations [PDF 121.9 KB]

Haematology

Consultation with the Paediatric Haematologist might also be required, at the direction of neurology and/or cardiology.

Investigation

The investigations of choice for TIA include:

  • MRI/MRA brain and neck is the imaging modality of choice. There is no indication for CT in TIA. Note: focal seizures are a differential, thus imaging should include applicable sequences as appropriate.
  • Echocardiogram and Bubble Study.

Treatments

Possible treatments that will be initiated on discharge under the direction of the Paediatric Neurologist include:

  1. Antithrombotic therapy
  2. Lifestyle modifications e.g. avoiding contact sports and activities that are high risk for cervico-cephalic arterial dissection)

Escalation and advice outside of ED

All patients with a suspected or confirmed acute ischaemic or haemorrhagic stroke should be escalated to the paediatric neurologist/neurosurgeon as described in this guideline. Please note that all children being treated for acute ischaemic or haemorrhagic stroke will require admission/retrieval to an appropriate tertiary/quaternary level PICU.

Critically unwell or rapidly deteriorating child (e.g. confirmed/suspected stroke)

Includes children with the following (as a guide)
  • Deteriorating level of consciousness
  • Loss of airway reflexes or bradypnoea/apnoea
  • Unilateral pupillary dilatation
  • New or worsening of existing neurological deficit
  • Seizures
  • Deterioration in vital signs
Reason for contact Who to contact
For immediate onsite assistance including airway management

The most senior resources available onsite at the time as per local practices.

Options may include:

  • paediatric critical care
  • critical care
  • anaesthetics
  • paediatrics
  • Senior Medical Officer (or similar)
Paediatric critical care advice and assistance

Onsite or via Retrieval Services Queensland (RSQ).

If no onsite paediatric critical care service contact RSQ on 1300 799 127:

  • for access to paediatric critical care, neurology and neurosurgical telephone advice
  • to coordinate the retrieval of a critically unwell child

RSQ (access via QH intranet)

Notify early of child potentially requiring transfer.

Consider early involvement of local paediatric/critical care service.

In the event of retrieval, inform your local paediatric service.

Non-critical child (e.g. suspected TIA with NO symptoms)

Includes children with suspected TIA and the following:

Discussion can be delayed overnight until morning if:

  • Well-examining children with normal vital signs
  • Completely resolved neurological symptoms prior to ED presentation
  • No recurrence of neurology
Reason for contact Who to contact
Neurology Advice (investigation, management, disposition and follow-up)

Options:

  • QCH switch (07) 3068 1111 (24-hour service)
  • Townsville University Hospital should contact the QCH/TUH Paediatric Neurologist using the internal roster

Inter-hospital transfers

Do I need a critical transfer?
  • Discuss with paediatric neurologist
Request critical transfer
Request a non-critical transfer

Disposition

All patients identified with an acute ischaemic or haemorrhagic stroke should be admitted to an appropriate quaternary/tertiary level paediatric intensive care unit for observation +/- definitive surgical therapies. For patients at peripheral sites, a retrieval will be organised through RSQ.

All patients identified with a TIA should be discussed with the Paediatric Neurologist prior to discharge home.

Related documents

  1. deVeber G. Delays in the timely diagnosis of stroke in children. Nat Rev Neurol. 2010;6:64-66.
  2. Mackay M, Chua Z, Lee M, Yock-Corrales A, Churilov L, Monagle P, et al. Stroke and nonstroke brain attacks in children. Neurology. 2014;82(16):1434-1440.
  3. Murphy S. Deaths: final data for 1998. Natl Vital Stat Rep. 2000;48:1-105.
  4. Giroud M, Lemesle M, Gouyon JB, Nivelon JL, Milan C, Dumas R. Cerebrovascular disease in children under 16 years of age in the city of Dijon, France: a study of incidence and clinical features from 1985 to 1993. J Clin Epidemiol. 1995;48(11):1343-1348.
  5. Sporns P, Bhatia K, Abruzzo T, Pabst L, Fraser S, Chung M, et al. Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study. Lancet Child Adolesc Health. 2024;8(12):882-890.
  6. Medley T, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, et al. Australian clinical consensus guideline: the diagnosis and acute management of childhood stroke. Int J Stroke. 2019;14(1):94-106.
  7. Lehman L, Watson C, Kapur K, Danehy A, Rivkin M. Predictors of stroke after transient ischemic attack in children. Stroke. 2016;47(1):88-93.
  8. Carey S, Wrogemann J, Booth F, Rafay M. Epidemiology, clinical presentation, and prognosis of posterior circulation ischemic stroke in children. Pediatr Neurol. 2017;74:41-50.
  9. Uohara M, Beslow L, Billinghurst L. Incidence of recurrence in posterior circulation childhood arterial ischemic stroke. JAMA Neurol. 2017;74(3):316-323.
  10. American Heart Association/American Stroke Association. Management of Stroke in Neonates and Children [slide set]. Dallas, TX: American Heart Association; 2019.
  11. Alexandrov AW, Shearin AJ, Mandava P, et al. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. Published online June 04, 2025. doi:10.1001/jamaneurol.2025.2253
  12. Ehtesham M, Mohmand M, Raj K, Hussain T, Kavita F, Kumar B. Clinical Spectrum of Hyponatremia in Patients with Stroke. Cureus. 2019 Aug 2;11(8):e5310. doi: 10.7759/cureus.5310. PMID: 31592365; PMCID: PMC6773452.

Key Stakeholders who reviewed this version.

  • Executive Director Medical Services, Queensland Children’s Hospital
  • Staff Specialists, Paediatric Emergency Medicine, Queensland Children’s Hospital, Townsville University Hospital, Gold Coast University Hospital, Sunshine Coast University Hospital, Toowoomba Hospital, Gladstone Hospital, Redcliffe Hospital, Logan Hospital
  • Nurse Unit Manager, Safety and Quality Nursing, Paediatric Emergency Medicine, Queensland Children’s Hospital
  • Staff Specialists, Paediatric Neurology Queensland Children’s Hospital
  • Nurse Unit Manager, Paediatric Neurology, Queensland Children’s Hospital
  • Director, Cardiology, Queensland Children’s Hospital
  • Divisional Director of Medicine, Queensland Children’s Hospital
  • Staff Specialists, Paediatric Intensive Care, Queensland Children’s Hospital
  • Staff Specialists and Radiographers, Radiology Department, Queensland Children’s Hospital
  • Neurointerventionalist, Radiology Department, Royal Brisbane and Women’s Hospital
  • Staff Specialist, Neurosurgical Department, Queensland Children’s Hospital, Townsville Hospital
  • Staff Specialist, Cardiac Surgery, Queensland Children’s Hospital
  • Staff Specialist, Haematology, Pathology Queensland
  • Staff Specialist, Haematology, Queensland Children’s Hospital
  • Pharmacist, Safety and Quality, Queensland Children’s Hospital
  • Pharmacist Lead, Critical Care, Queensland Children’s Hospital
  • Senior Lawyer, Queensland Children’s Hospital
  • Staff Specialists, CHQRS, Queensland Children’s Hospital
  • Director, Retrieval Services Queensland
  • Director, Clinical Policy Governance, Queensland Ambulance Service
  • Statewide Stroke Committee
  • Statewide Emergency Care of Children Working Group

Document ID: CHQ-GDL-00734

Version number: 3.0

Supersedes: 2.2

Approval date: 24/10/2025

Effective date: 29/10/2025

Review date: 24/10/2028

Executive sponsor: Executive Director Medical Services

Author/custodian: Queensland Emergency Care Children Working Group

Applicable to: Queensland Health medical and nursing staff

Document source: Internal (QHEPS) + External

Authorisation: Executive Director Clinical Services

Keywords: stroke, paediatric stroke, Alteplase, tPA, rtPA, clot retrieval, endovascular thrombectomy, thrombectomy, hyperacute therapies, reperfusion therapies, reperfusion, emergency, PICU, neurology, neurosurgery, radiology, cardiac surgery, cardiology, anaesthetics, anaesthesia, interventional radiology, interventional neuroradiology, 00734

Accreditation references: NSQHS Standards (1-8): Standard 1 Clinical Governance (Actions 1.6, 1.27 and 1.7), Standard 5 Comprehensive Care (Actions 5.2, 5.7 and 5.13), Standard 6 Communication for Safety (Actions 6.5, 6.6 and 6.7), Standard Recognising and Responding to Acute Deterioration (Actions 8.1, 8.4, 8.5, 8.6, 8.9 and 8.10)

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.

This governance document has been human rights compatibility assessed. No limitations were identified indicating reasonable confidence that, when adhered to, there are no implications arising under the Human Rights Act 2019.

Last updated:   November 2025

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