Stroke Screening questions/ Initial Assessment
1. Is there a focal neurologic deficit?
     a. Unilateral weakness or sensory changes

     b. Vision loss or double vision
c. Speech or language difficulty: dysarthria/aphasia
d. Dizziness, trouble walking or ataxia
2. Did the symptoms start suddenly OR get worse suddenly?
3. Was the child last seen well within 5 hours?

  • Obtain Venous Access
    Labs: CBC, BMP, coagulation studies, and EKG
  • NPO and head of bed flat 
  • Normotension: target SBP between 50th percentile and 15% above 95th percentile for age, treat hypotension with NS +/- pressors, treat significant HTN , to lower by 25% over 24 hours
  • Normovolemia: isotonic fluids at maintenance
  • Normoglycemia: no glucose in fluids unless hypoglycemic
  • Normal O2, CO2, pH
  • Normothermia: treat patient with T> 37 Celsius with acetaminophen
  • Seizure control: AED ASAP
  • Obtain Acute Stroke imaging (MRI brain: DWI, T2 Flair, ASL, SWAN and MRA head); if MRI not possible, combination CT/CT angiogram can be considered                           
    • (+) hemorrhagic stroke: consult Neurosurgery
    • (-) hemorrhage stroke
      • evidence of early infarct, free of hemorrhage, and w/ evidence of vascular occlusion
        • Time from onset + estimated time to arrival ≥ 4.5 hours, or age ≤ 2 years or resolving deficits or tPA contraindication**  → Admit to PICU
        • Time from onset + estimated time to arrival ≤ 4.5 hours and age ≥ 2 years, and persistent deficit and no tPA contraindications** → consider tPA
  • For tPA, should have BOTH proven infarct AND arterial occlusion on MR    
    • IF tPA candidate

      • Total Dose: Alteplase (tissue plasminogen activator 1mg/ml), 0.9 mg/kg IV
      • Bolus: 10% dose IV over 1-2 minutes
      • Infusion: remaining 90% over 1 hour
      • Maximum total dose: 90 mg                                                          

  • PICU Management
    • Continuous cardiac monitoring
    • Transthoracic ECHO with bubbles
    • Consider 4 Extremity Doppler
    • EEG if seizure activity suspected
    • Neuro Checks Q1 hour
    • DVT prophylaxis with compression devices
    • Labs: Coags, ESR, CRP, Lactate, Tox screen, Urine pregnancy. Blood culture
    • Consider LP for infectious/inflammatory etiologies
    • Hx Sickle cell: reticulocyte count, Hemoglobin S%, type/cross, call HEME
    • Send relevant supplemental labs with aid of neurology and hematology


  • Initial Therapy per neurology (if no hemorrhage)
    • Aspirin3-5mg/kgdaily(MAX 162 mg)
    • If cardiac source or cervicocerebral dissection suspected initiate unfractionated heparin IV (goal anti-factor Xa level 0.35-0.7)

**Tissue Plasminogen Activator (tPA) contraindications**


  • > 4.5 hrs from last seen well
  • Patients in whom time of symptom onset is unknown
  • Stroke, major head trauma or intracranial surgery in the last 3 months
  • History of prior intracranial hemorrhage, known AVM or aneurysm
  • Major surgery or parenchymal biopsy within 10 days
  • GI or GU bleeding within 21 days
  • Patient with neoplasm/malignancy or within one month of completion of treatment for cancer
  • Patients with underlying significant bleeding disorder. Patients with mild platelet dysfunction , mild von Willebrand disease or other mild bleeding disorders are not excluded
  • Previously dx d primary angiitis of the central nervous system or secondary arteritis.


  • Patient who would decline a blood transfusion if indicated.
  • Clinical presentation c/w acute myocardial infarction or post MI pericarditis that requires evaluation by cardiology before treatment
  • Arterial puncture at non-compressible site or lumbar puncture w/in last 7 days. Patients who have had cardiac cath via a compressible artery are NOT excluded.


  • Stroke due to SBE, sickle cell disease, meningitis, embolism (bone marrow, air or fat), or moyamoya disease.


  • Persistent systolic blood pressure >15% above the 95th percentile for age while sitting or supine
  • Mild deficit (PedNIHSS <6) at start of tPA infusion
  • Severe deficit suggesting very large territory stroke pre -tPA 
  • PedNIHSS >25, regardless of infarct volume seen on neuroimaging


  • Symptoms suggestive of SAH even if CT or MRI of head are normal 
  • CT with hypodensity/sulcal effacement >33% of MCA territory / ASPECTS ≤7
  • Intracranial cervicocephalic arterial dissection.


  • Glucose <50 mg/dL (2.78 mmol/L) or >400 mg/dL (22 mmol/L)
  • Bleeding diathesis including Platelets <100,000, PT >15 sec (INR >1.4) or elevated PTT > upper limits of the normal range.