A stroke is often thought of as a condition of adulthood, yet it remains a significant and underrecognized cause of morbidity and mortality in the pediatric population. Despite being cited among the leading causes of death in children, pediatric stroke is frequently missed or diagnosed late, in part due to its relative rarity, diverse clinical presentations and the unique risk factors that distinguish it from adult stroke. As a result, many children with stroke present outside the narrow window during which acute interventions may be considered, limiting opportunities for therapies that can meaningfully alter neurologic outcomes. In pediatric stroke, as in adult stroke, the principle remains the same: Time is brain.
Improving pediatric stroke education
Sarah Novara, M.D., MSQHS, FCNSDuring her training in child neurology at the University of Alabama at Birmingham (UAB), Sarah Novara, M.D., MSQHS, FCNS, associate professor in the Division of Pediatric Neurology, had several patient encounters that highlighted both the devastating potential of delayed stroke recognition in children and the extraordinary opportunity that exists when stroke is identified and treated promptly.
“When we were able to quickly evaluate and treat stroke symptoms in our pediatric patients, we saw amazing neurologic recovery,” explains Novara. “Seeing the importance of early stroke recognition firsthand inspired me to improve our pediatric stroke education and standardization processes at Children’s of Alabama and UAB.”
As a senior resident, Novara developed pediatric stroke education and streamlined order sets and processes for residents, fellows and faculty. Novara worked with Tony McGrath, M.D., associate professor in the Division of Pediatric Neurology and Nancy Tofil, M.D., M.Ed., professor in the Division of Pediatric Critical Care, to develop a pediatric stroke simulation as part of pediatric stroke education for trainees and faculty. “The simulation has been highly efficacious in advancing pediatric stroke evaluation and management knowledge in a variety of learner settings since its creation,” explains Novara.
From education to systems change: Creating a pediatric code stroke
Tony McGrath, M.D.Once on faculty at UAB, Novara continued her work with pediatric stroke education and began working on improving early stroke recognition among providers at Children’s of Alabama and UAB by establishing a Code Stroke for pediatrics.
“We decided to model a Code Stroke process after our adult neurology colleagues and other select children’s hospitals across the US,” explains Novara. The pediatric Code Stroke initiative aims to offer necessary, efficient evaluation and management of patients presenting with signs of possible stroke and if inevitably they have not had a stroke, the Code Stroke process assists in evaluating and managing conditions that mimic stroke and deserve appropriate treatment.
In the summer of 2024, the Code Stroke working group met to create the Children’s of Alabama Code Stroke protocol for patients greater than one month of age with acute neurologic deficits and who were last known at their neurologic baseline less than 24 hours prior to presentation at the hospital. This is the window in which options of acute stroke intervention may be offered, if there are no contraindications. In addition to the protocol, order sets within EPIC were streamlined for the evaluation of Code Stroke patients in the emergency department (ED) or on the hospital floors and stroke patient admission order sets were provided as well.
Nancy Tofil, M.D.This Code Stroke effort was spearheaded by Drs. Novara and Tofil and Jeffrey Blount, M.D., MPH, professor in the Division of Pediatric Neurosurgery and included colleagues from pediatric emergency medicine, neuro-interventionalists, radiology, nursing and operators.
After the Code Stroke protocol was established and education was provided across the pediatric divisions, the Children’s of Alabama Code Stroke went live in September 2024. As of December 2025, a Code Stroke has been called 90 times (either in the ED or on a hospital floor). Approximately 15% of these Code Strokes have identified ischemic or hemorrhagic strokes, allowing for efficient evaluation and management. Several of the pediatric acute ischemic stroke patients have even benefited from an acute thrombectomy performed by the on-call neuro-interventionalists. Code Stroke patients with hemorrhagic stroke have benefited from the expedited care of the pediatric neurosurgery team. Many of the Code Stroke patients have made remarkable recoveries.
“The Code Stroke working group meets quarterly to continuously discuss ways in which to improve our Code Stroke protocol and to collaborate together as we try to provide the best care for our patients,” explains Tofil.
Expanding care beyond the acute phase: Pediatric stroke clinic
In early 2025, a monthly Stroke Clinic was established by Drs. Novara and McGrath to provide a unique pediatric stroke follow-up clinic that offers ongoing patient support, education and follow-up care, including best efforts at secondary stroke prevention.
Jeffrey Blount, M.D.In the monthly stroke clinic, the pediatric neurology team collaborates with pediatric hematology and neurosurgery colleagues in the care of unique pediatric patient populations seen in their clinics who are at risk for stroke. The stroke clinic also allows the pediatric neurology team to provide effective transition of care for patients from pediatric to adult stroke care at UAB as needed.
The pediatric stroke clinic at Children’s of Alabama is a participating site within the International Pediatric Stroke Study, which is a research group working hard within the International Pediatric Stroke Organization to expand the knowledge about pediatric stroke and best practices for these unique patients.
The Code Stroke program has demonstrated that targeted educational initiatives, combined with the development of standardized, multidisciplinary response protocols, can meaningfully improve the evaluation and management of children presenting with possible pediatric strokes.
As awareness grows and standardized care pathways expand, there is an opportunity to reduce the burden of pediatric stroke and ensure that children receive timely, evidence-informed care when minutes matter most.