Childhood stroke, although similar to adult stroke, is characterized by congenital and genetic causes. The evaluation and treatment of the child with stroke requires special considerations. Currently, drug therapy is untested and as a result, therapeutic interventions are problematic. Platelet antagonists are rational prophylactically; warfarin probably has a role in preventing cardiogenic embolus in the older child. However, chronic anticoagulation in the toddler is dangerous due to frequent trauma and is therefore relatively contraindicated. Vascular malformations are surgically repaired but alternative therapies, including radiation and embolization, may be used for inoperable lesions. Aneurysms are primarily surgical lesions. Newer imaging modalities will clarify the pathophysiologic picture and improve treatment.