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  • Both ischemic and hemorrhagic strokes occur in children. The incidence varies across countries but ranges from 1 to 5 per 100,000 per year. Approximately 55% are ischemic strokes and 45% hemorrhagic.

  • Ischemic strokes are caused by vascular occlusion of an artery, usually because of thromboembolism (arterial ischemic stroke [AIS]) or occlusion of venous sinuses or cerebral veins (cerebral venous sinus thrombosis [CSVT]).

  • Strokes that can result from vascular rupture are classified as hemorrhagic. The two main types are intracerebral hemorrhage and subarachnoid hemorrhage (SAH).

  • A history of complex congenital heart disease, prosthetic heart valve, recent cardiac surgery, or extracorporeal membrane oxygenation (ECMO) should raise suspicion of an embolic phenomenon.

  • Magnetic resonance imaging (MRI) with diffusion-weighted imaging is more sensitive in detecting small infarcts, infarcts of the brain stem and cerebellum, and infarcts that become hemorrhagic, and is more sensitive for acute ischemia than a computed tomography (CT) scan.

  • A CT scan will show a tumor, large bleed, or abscess, and may show loss of gray/white differentiation and dense triangle sign (hyperdense thrombus in the posterior part of superior sagittal sinus), but may not detect some acute hemorrhages.

  • Magnetic resonance angiography (MRA) can be done at the time of the MRI to visualize the flow through the cerebral arteries. MRI can also be used with magnetic resonance venography (MRV) to diagnose sinovenous thrombosis.

  • For patients in whom a hemorrhagic stroke is suspected and in whom the CT scan is negative, a lumbar puncture is indicated. Particularly with a small subarachnoid hemorrhage, the CT scan may not reveal blood.

  • The key function of the emergency department (ED) is stabilization of the patient’s respiratory and cardiovascular status, especially the blood pressure. In the event of an ischemic infarct, a precipitous decline in blood pressure should be avoided, since it can worsen cerebral ischemia, but if hypotension is present, careful fluid resuscitation and inotropic support may be needed.

  • Serum glucose should be monitored closely, as hypoglycemia can worsen the effect of the stroke, and hyperglycemia can increase infarct size.

  • Specific therapy is directed at the etiology of the stroke, such as correction of clotting abnormalities, antibiotics for infections, antiepileptic medication for seizures, transfusion for anemia, and surgery for evacuation of a hematoma. For patients with sickle cell disease, exchange transfusion is indicated for ischemic stroke.

Although they are uncommon in children when compared to adults, both ischemic and hemorrhagic strokes occur. The incidence varies across countries but ranges from 1 to 5 per 100,000 per year.1,2 Approximately 55% are ischemic strokes and 45% hemorrhagic.1,3 Ischemic strokes can be categorized as arterial ischemic strokes (AIS) and cerebral venous sinus thrombosis (CSVT). AIS accounts for 75% of ischemic strokes, while CSVT accounts for 25%.2 In the pediatric population, AIS usually results from a thromboembolism. Occlusion of venous sinuses or cerebral veins can result in CSVT. The majority of ischemic and hemorrhagic strokes occur in the neonatal ...

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