Objective:

To review the effectiveness of a Pediatric Code Stroke (PCS) pathway in identifying patients with Serious Acute Neurologic Events (SANE).

Background:

The recognition and evaluation of Pediatric Stroke (PS) is complicated by frequent mimics. While this is acknowledged in multiple prior reports, there is no consensus for how to approach patients presenting with SANE.

Design/Methods:

A PCS pathway was implemented at our tertiary care center and we conducted a retrospective chart review of PCS activations between August 2024 and September 2025. Stroke mimics were categorized as benign (e.g. migraine, syncope, psychogenic) or serious (e.g. focal seizure, meningoencephalitis, brain tumor) based on the identification of an acute evolving process requiring intervention and the potential for persistent neurologic deficit.

Results:

There were 48 PCS activations with a median age of 12 years (range 3 months to 17 years) of which 58% were male. Neuroimaging was obtained in 42 patients, with 39 receiving MRI. Six activations (12.5%) identified acute cerebrovascular events, but none qualified for acute revascularization. Seventeen activations (40.5%) identified serious mimics with seizures and emesis being the most common symptoms while 25 (59.5%) identified benign mimics with headaches, language/sensory changes, and ataxia predominating. Patients diagnosed with serious mimics were more likely to have at least one stroke risk factor (65% vs 12%, p < 0.001). They were also more likely to require acute treatment and receive further diagnostic evaluation that changed management (82% vs 36%, p < 0.01).

Conclusions:

While few patients were identified with an acute cerebrovascular event, PCS activations identified SANE in 48% of our cohort. We propose an algorithm for the evaluation and management of patients presenting with SANE as an alternative to a PCS protocol which may be beneficial for other tertiary care centers.