• neurology
• paediatrics
• paediatric emergency medicine

In August 2017, the Royal College of Paediatric and Child Health (RCPCH) published guidelines for the management of stroke in childhood between 1 month and 18 years of age (see hyperlink). This comprehensive 169-page publication is a National Institute for Health and Care Excellence (NICE)-accredited multiprofessional evidence-based guideline that provides recommendations for the management of stroke in children and young people. A small proportion of the guideline focuses on acute ischaemic stroke management with thrombolysis. Only a small number of children will be eligible for consideration for thrombolysis; however, it is important that we strive to implement pathways so that as many eligible children as possible can be considered. At present, the window for thrombolysis is 4.5 hours from stroke onset. That means that the clock starts to tick the second the symptoms start (and in the case of a wake-up stroke, from the time that the child was last seen to be well). Four years on from publication, we provide commentary on the challenges of implementation of the acute management component of the paediatric stroke guidelines and how they may be overcome.

Establishing the clinical diagnosis of ischaemic stroke and the urgency that should go with it is a major challenge. This happens both in the community and in hospital. As the majority of strokes happen in the ageing adult population, most people do not consider it a possibility in children. The FAST (Face, Arms, Speech, Time) campaign in the UK increased the rate of adult stroke thrombolysis by fivefold.1 While it may not be practical from a public health perspective to run a similar …