Presentation with stroke is rare in children, with an incidence of 2.6 and 3.1/100 0000 white and black children, respectively.1 Half are haemorrhagic, requiring immediate transfer to a neurosurgical unit in case decompression is required. Traditionally, ischaemic strokes have been considered to be idiopathic and to have a good prognosis, with a low recurrence risk and good recovery of motor function and school performance. They have not been investigated extensively, on the basis that management would not alter. However, there is a significant mortality,1 as well as considerable morbidity and a risk of recurrence, none of which has been adequately defined epidemiologically. In addition, there is now evidence that the neurological outcome could be improved, at least in some subgroups, by appropriate emergency management and, particularly, that recurrence might be preventable. This article proposes essential investigations and management for “good practice” in the current state of knowledge, although further research is clearly required before evidence based guidelines can be produced.