You’re dispatched to a 6-year-old boy who has collapsed at school during a PE lesson. His teacher describes a sudden loss of balance, some funny speech, and what seemed to be a loss of power in the right arm. He seems alert now, but is very quiet.
His mum arrives, distraught, insisting that despite the teachers being relieved, he just ‘isn’t right!’
There’s no seizure, blood glucose is normal, his speech doesn’t seem slurred to you, but mum says it’s ‘slower’ than normal. FAST Positive? Unclear. Migraine? Post-ictal? Something else?
As a paramedic, what do we do next?
Stroke is often thought of as an adult – or even exclusively an elderly adult – diagnosis. But stroke in children, whilst rare, is real, and the implications of a missed diagnosis are enormous for the child and their loved ones. Around 400 children a year in the UK experience a stroke, and up to half of them have an initial misdiagnosis and subsequent delay to definitive care. Imagine the scandal if half of all adult stroke diagnoses were made incorrectly in the pre-hospital setting?
Unlike many adult cases, children rarely present in a textbook way when it comes to stroke. They may exhibit very vague, nonspecific symptoms, and in many cases, the FAST assessment does not apply cleanly. As pre-hospital clinicians, we may often be the first to assess these children, but arguably lack the education or experience to suspect or recognise paediatric stroke confidently. This is a missed opportunity – pre-hospital clinicians have a privileged role in often being able to see clinical presentations much closer to their origin. Early clinical suspicion from paramedics may therefore be a crucial first step in triggering timely investigation and diagnosis, acting as a catalyst for earlier recognition and improved outcomes.
This blog explores paediatric stroke through the lens of a pre-hospital paramedic: what to look for, who is most at risk, how to act quickly, and what to do when FAST might not be fast enough.
What is Paediatric Stroke?
Strokes in children fall broadly into two categories:
- Arterial ischaemic stroke (AIS) – caused by an interruption in blood supply – is the most common cause
- Haemorrhagic stroke – less common, and often related to vascular abnormalities
Unlike adult stroke, paediatric AIS is often secondary to other conditions – clotting disorders, infections, cardiac disease, or trauma being the most common. Children also experience many of the stroke mimics also seen in adults, such as seizures, Bell’s palsy, and migraines; complicating the task of early recognition.
Why Recognition is Hard – Especially Pre-Hospital
Half of paediatric strokes are not initially recognised, with common misdiagnoses ranging from migraine and viral illness to behavioural concerns. Although this particular study is nearly a decade old, and we might hope that awareness has since improved, the literature offers little reassurance. Notably, there remains a scarcity of published research specifically focused on UK-based practice, both in pre-hospital and hospital settings, which represents an important gap and a key direction for future study.
Several challenges to early recognition are particularly pronounced in the pre-hospital environment:
- FAST is not validated in children: While it is a well-established and widely promoted tool for identifying adult strokes, the sensitivity of the Face-Arm-Speech-Time assessment is significantly reduced in patients under 16.
- Children compensate well: Vital signs can remain deceptively normal despite significant neurological compromise, potentially masking serious pathology.
- Communication limitations: Very young or non-verbal children may be unable to describe their symptoms, requiring clinicians to detect subtle behavioural or physical cues.
- Low clinical suspicion: Due to its rarity, paediatric stroke may not be front-of-mind for many pre-hospital clinicians. For instance, stroke in children is only briefly referenced in the UK pre-hospital clinical practice guidelines, known colloquially as JRCALC, and many local trust pathways lack specific direction for managing suspected cases in this age group.
What Can Pre-Hospital Clinicians Do?
Despite these barriers, there are practical steps paramedics can take to improve recognition and care for children with suspected stroke:
Use FAST – but don’t rely solely on it: FAST certainly remains a helpful tool in children, and any abnormalities found on assessment should result in high clinical suspicion. However, the framework is not sensitive enough, particularly in younger patients and those presenting with atypical symptoms. Therefore, in the absence of a validated tool, clinical judgement remains key. When in doubt – escalate and communicate concerns.
Don’t get caught out by those mimics. Consider them, and by all means suspect they have a higher likelihood than stroke; but don’t be falsely reassured by them. Stroke may still need to be ruled out urgently.
Act fast. Timely recognition of paediatric stroke is critical, as children, particularly adolescents, may still be eligible for medical interventions such as thrombolysis or even mechanical thrombectomy. These interventions can be highly time-sensitive and depend on prompt clinical suspicion and rapid imaging. The earlier specialist paediatric neurology teams can be aware and involved, the better the outcome may be.
Although much work remains to standardise protocols and expand access, an emerging body of evidence supports the benefit of timely intervention. For example, a 2024 prospective study by Sporns et al. demonstrated improved outcomes following endovascular thrombectomy in childhood stroke when compared to thrombolysis or conservative management. Further research is essential to build a stronger foundation of evidence to guide practice, however.
Pre-alert, escalate concerns, and consider transporting wisely. If stroke is suspected, communicate these concerns. Consider the location of your nearest imaging-capable or tertiary paediatric hospital, and while respecting local trust guidelines, utilise on-call or senior clinical advice structures when there is significant clinical suspicion of paediatric stroke. At the same time, take care to avoid delay with non-urgent assessments; definitive care remains the priority
Listen to the parents: ‘he’s not himself’ or ‘she’s acting very strange’ may sound vague – but this may often be your most important clue. Trust parental instinct – and yours.
Tips for the Pre-Hospital Clinician
So, what specifically should we be looking out for on-scene to help maintain our index of suspicion?
Neurological Signs (often sudden onset)
- Facial droop
- Limb weakness, or decreased movement (particularly if unilateral)
- Slurred, or slower speech, or difficulty in understanding that is different from baseline
- Ataxia, or unsteady gait
- Focal seizures (especially if first-time seizures)
Non-specific but suspicious signs
- Altered consciousness or drowsiness
- Neck pain
- Persistent nausea, vomiting or headache (particularly if one-sided or if woken by it)
- Behavioural change (withdrawn, unexplainably irritable, or ‘just not right’)
In young children
- Reduced feeding
- Floppiness
- Asymmetric limb use that can’t be otherwise explained
You ask the patient’s mum whether her son has any medical history – Sickle Cell Disease is a known diagnosis, although he has been well recently and not had a crisis in quite some time.
Risk Factors Definitely Worth Knowing
Certain children are at significantly increased risk of stroke:
– Sickle cell disease – a major cause of childhood stroke
– Congenital heart disease, or recent surgery (a 19-fold increase in risk)
-Infection (the risk of thrombotic stroke is six times higher following recent chickenpox, or a cold/flu illness)
– Clotting disorders
– Unvaccinated children (associated with an eight times higher risk)
– Previous stroke
Conclusion
The child in our vignette was ultimately diagnosed with an ischaemic stroke, with his underlying sickle cell disease contributing significantly to the event. Thanks to the vigilance of the attending paramedic, an approach grounded in caution and concern resulted in a pre-alert to the nearest pediatric emergency department with imaging capability. The child was imaged within 90 minutes of arriving due to the clinical suspicion, and subsequently received exchange transfusion under the specialist guidance and care of a paediatric stroke centre and haematology team.
As pre-hospital clinicians, we might only see a handful of suspected paediatric stroke cases in a whole career – but correct recognition and care may have a life-long positive impact on those children and their families.
Take home points
Paediatric stroke is rare, but serious and often misdiagnosed.
FAST may not be sufficient – look for a broader spectrum of symptoms, particularly if you are concerned.
Trust your gut, and the parents or caregivers! If it feels like something is wrong – communicate and escalate your concerns.
Time is brain; just like in adults, delays may have a lifelong impact.
Pre-hospital clinicians would benefit from more education and guidance with paediatric stroke; if you are in a position to help with this, then do advocate for this group of patients.
References
Joint Royal Colleges Ambulance Liaison Committee and Assoociation of Ambulance Chief Executives [JRCALC]. (2025). JRCALC Pre-Hospital Clinical Guidelines [Mobile Aplication]. Available at: https://www.jrcalc.org.uk/. Last accessed: 17th April 2025.
Mackay M, Monagle P and Babl, F. (2017). Improving diagnosis of childhood arterial ischaemic stroke. Expert Review of Neurotherapeutics. 17 (12), p1157-1165.
Stojanovski B, Monagle P, Mosley I, Churilov L, Newall F, Hocking G & Mackay, M. (2017). Prehospital Emergency Care in Childhood Arterial Ischaemic Stroke. Stroke. 48 (4).
Stojanovski B, Monagle P, Newall F, Chuirlov L, Mosley I, Hocking G & Mackay, M. (2016). Paramedic Management of Childhood Arterial Ischaemic Stroke. Stroke. 47 (1), p1-10.
Mackay M, Monagle P & Babl, F. (2016). Brain attacks and stroke in children. Journal of Paediatrics and Child Health. 52 (2), p158-163.
Sporns P, Fullerton H, Lee S, Kim H, Lo W, Mackay M & Wildgruber, M. (2022). Childhood stroke. Nature Reviews Disease Primers. 8 (12).
Mackay M, Chuirlov L, Moon A, McKenzieg I, Donnanc G, Monagle P, Li Q & Babl, F. (2021). Identification of barriers and enablers to rapid diagnosis along the paediatric stroke chain of recovery using Value-Focused Process Engineering. Health Systems. 10 (1), p73-88.
Mastrangelo M, Giordo L, Ricciardi G, de Michele M, Toni D, Leuzzi, V. (2022). Acute ischaemic stroke in childhood: a comprehensive review. European Journal of Paediatrics. 181 (1), p45-58.
Long E, Saw J, Davis C, Morgan C, Sheridan B, Monagle P, Ryan M, Macdonald-Laurs E & Mackay, M. (2021). Paediatric Code Stroke. Journal of Paediatric Child Health. 58 (2), p356-359.
