Our objective was to determine the incidence rate of stroke and stroke subtypes in children. We reviewed the medical records, autopsy records, and brain imaging studies of all children with a possible stroke within the Greater Cincinnati metropolitan area population of nearly 1.3 million during 1988 and 1989. Traumatic brain hemorrhages and germinal matrix hemorrhages were excluded. Of the 295,577 children in Greater Cincinnati, medical records of 178 children were screened. Sixteen cases (13 whites and three blacks) less than age 15 years fit strictly defined criteria for first-ever stroke. The incidence rate for cerebral infarction was 1.2 cases per 100,000 (95% confidence interval, 0.3 to 2.0). The combined incidence rate for intracerebral hemorrhage and subarachnoid hemorrhage was 1.5 cases per 100,000 children (95% confidence interval, 0.4 to 2.3). The incidence rate of all stroke in white children was 2.6 cases per 100,000 (95% confidence interval, 1.2 to 4.1), compared to 3.1 per 100,000 in black children (95% confidence interval, 0 to 6.6). The combined 30-day mortality for intracerebral hemorrhage and subarachnoid hemorrhage was 22% (two of nine) compared to 14% (one of seven) for cerebral infarction. We conclude that in contrast to the picture in adults, hemorrhagic stroke among infants and children is at least as common as ischemic infarction. (J Child Neurol 1993;8:250-255).