Abstract Body: INTRODUCTION: Pediatric stroke, while one of the top 10 causes of mortality among U.S. children, remains underrecognized. Identification of pediatric stroke begins with those in the community and emergency medical services (EMS) who must recognize acute neurological symptoms (ANS) in a child as a medical emergency and appropriately triage these patients to facilitate urgent imaging. To describe the current state and inform quality improvement efforts, we examined (1) timing and predictors of neuroimaging among children with EMS activation for ANS, and (2) arrival modality and symptoms of children with acute stroke presenting to the emergency department (ED). METHODS: This is a retrospective study of patients 1-14 years with an EMS activation for ANS (based on EMS primary symptom and impression codes) who were transported to Children's Hospital Orange County (CHOC) ED from 1/2019-6/2023 (Figure 1). We also identified all out-of-hospital strokes admitted to CHOC (ICD-10 search of discharge diagnoses) and determined the proportion of strokes presenting via EMS. We excluded those with major trauma or epilepsy. RESULTS: Of 3888 children with EMS activations for ANS, 695 (17.9%) had neuroimaging: 570 (82.0%) had CT scan only; 125 (18.0%) also had MRI (Table 1). The median and IQR times to CT and MRI were 2.29 (1.56, 3.21) and 26.8 (16.3, 43.8) hours, respectively. Factors associated with imaging included age ≥5 years (p<0.001) and known medical conditions associated with increased stroke risk (<0.001). All patients with EMS primary impression codes of stroke had neuroimaging. Combining these data with the ICD-10 search, we identified 43 admissions for out-of-hospital acute stroke (Figure 2). Of those presenting with EMS activations, primary symptoms and impression codes were seizure, altered mental status, loss of consciousness, and headache, but not stroke. Of those who presented as ED walk-ins, the most common chief complaints were head injury and general neurologic complaint. CONCLUSIONS: Most children with EMS activations for ANS were not imaged; of those who were many had only CT and not MRI, the preferred imaging modality for diagnosing pediatric ischemic stroke. The many children who arrived as walk-ins suggests a lack of community awareness of pediatric stroke. Our findings call for more education of lay people and prehospital/ED providers of pediatric stroke, as earlier consideration may expedite diagnosis and increase opportunities for intervention.