Guidelines in Action - Pediatric Acute Ischemic Stroke Treatments - Thrombolysis and Thrombectomy

Oct 13, 2026

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Two illustrative pediatric acute ischemic stroke cases describe rapid evaluation and targeted reperfusion decisions. Case 1 (age 14) received IV alteplase at 3.5 hours and later endovascular thrombectomy achieving full MCA recanalization, followed by aspirin-based secondary prevention and neurological recovery with mild residual effects. Case 2 (age 2) did not receive thrombolysis due to age and an out-of-window presentation; thrombectomy achieved >50% distal reperfusion, with anticoagulation management for ventricular thrombus complicated by petechial hemorrhage and later transition to oral rivaroxaban.

LanguageEnglish

CategoryHealthcare

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Pages4

Reading Time10 min

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Illustrative teaching cases

Case 1

Case 2

Key words

Downloaded from [http://ahajournals.org by on October](http://ahajournals.org by on October) 13, 2026 ILLUSTRATIVE TEACHING CASES Section Editors: Sophia Sundararajan, MD, PhD, and Alexis N. Simpkins, MD, PhD, MSCR Guidelines in Action: Pediatric Acute Ischemic Stroke Treatments (Thrombolysis and Thrombectomy) Rachel Vassar, MD; Heather J. Fullerton, MD, MAS CASE 1 A 14-year-old right-handed boy with chronic ileitis presented with a seizure followed by confusion, left-sided weakness, and rightward gaze deviation. On arrival atthe outside hospital, his National Institutes of Health Stroke Scale score was 9. Computed tomography (CT) with angiography of the head and neck revealed a right internal carotid artery terminus to proximal middle cerebral artery (MCA) occlusion (Figure 1A) . He received intravenous alteplase (0.9 mg/kg) at 3.5 hours since last known well and was promptly transferred to a hospital with pediatric neurointerventional radiology. Initial angiogram demonstrated right internal carotid artery recanalization but occlusion of the proximal M2 MCA (dominant branch) and A2 anterior cerebral artery (Figure 1B) . The M2 branch thrombus was successfully retrieved via endovascular thrombectomy with full MCA recanalization at 5 hours since last known well with Thrombolysis in Cerebral Infarction score: 3. Removal of the A2 thrombus was not attempted. He was admitted to the pediatric intensive care unit for close neuromonitoring. On poststroke day 1, his National Institutes of Health Stroke Scale score was 1 (mild facial asymmetry), and brain magnetic resonance imaging and angiography at 24 hours postthrombolysis demonstrated infarction in the right basal ganglia, caudate, insula, and frontal operculum (Figure 1C), with patent right MCA branches (Figure 1D) . He was initiated on aspirin 325 mg daily for secondary stroke prevention, transitioned to 81 mg daily at discharge on day 5. His presumed stroke cause was paradoxical emboli in the setting of patent foramen ovale identified on transesophageal echo, with possible contribution of hypercoagulability related to his ileitis. Three months later, the patient had returned to school and was functioning near his prestroke baseline, although he noted subtle cognitive differences and mild exertional leftsided weakness. CASE 2 A 2-year-old boy with hypoplastic left heart syndrome experienced a sudden onset of stiffening, loss of consciousness, and apnea concerning for seizure. As he arose, he was noted to have right-sided weakness. He was brought to a community hospital and emergently transferred to a pediatric stroke-capable facility. He arrived 5 hours since last known well with a pediatric National Institutes of Health Stroke Scale score of 11 (modified to be developmentally appropriate, otherwise consistent with the adult National Institutes of Health Stroke Scale score) . He did not receive intravenous thrombolysis because of his age, in addition to being outside the 4.5-hour window. Emergent brain magnetic resonance imaging/magnetic resonance angiography revealed left basal ganglia and cerebellar infarcts with a distal M1 occlusion (Figure 2A and 2B) . Perfusion imaging was not obtained. He was in atrial flutter, and echocardiogram demonstrated severely decreased ventricular function and left ventricular thrombus. He underwent cardioversion and was taken emergently to the neurointerventional suite, where a cerebral Key Words: angiography ◼ magnetic resonance imaging ◼ stroke ◼ thrombectomy ◼ thrombolytic therapy Correspondence to: Rachel Vassar, MD, Departments of Neurology and Pediatrics, University of California, San Francisco, 675 Nelson Rising Ln, Room 402-A, San Francisco, CA 94158. Email [rachel.vassar@ucsf.edu](rachel.vassar@ucsf.edu) © 2026 American Heart Association, Inc. Stroke is available [at www.ahajournals.org/journal/str](at www.ahajournals.org/journal/str) e304 August 2026 Stroke. 2026;57:e304–e307. DOI: 10.1161/STROKEAHA.125.053

FAQs

What imaging and time-critical steps guided treatment in Case 1?

Computed tomography with angiography identified a right internal carotid terminus to proximal MCA occlusion, leading to IV alteplase at 3.5 hours and subsequent transfer for pediatric neurointerventional care. Initial angiography showed recanalization of the internal carotid but persistent proximal M2 and A2 occlusions, prompting endovascular thrombectomy for the M2 thrombus.

Why was IV thrombolysis not used in Case 2?

IV thrombolysis was not given because of the patient’s age and presentation outside the 4.5-hour window, despite a developmentally adjusted pediatric National Institutes of Health Stroke Scale score and confirmatory MRI/MRA findings.

How were complications related to anticoagulation managed after thrombectomy in Case 2?

After thrombectomy, bivalirudin anticoagulation was started for ventricular thrombus. Repeat imaging showed petechial hemorrhage and a persistent distal M2 thrombus, so bivalirudin was paused due to hemorrhage, then restarted on day 3 after clinical and radiographic stability, followed by transition to oral rivaroxaban on day 7.

Oct 13, 2026

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