Pediatric stroke incidence is rare and occur between 2 to 8 per 100,000 annually. Large vessel occlusion is even rarer in the pediatric population, many of whom are affected by high rates of morbidity and mortality.  Large vessel occlusions respond to IV-TPA in less than 20%.  Here, we describe a pediatric patient with a large vessel occlusion who responded to IV-TPA with an excellent clinical outcome.    

A 16-year-old caucasian male with no significant past medical history presented to ER via EMS with acute onset of left hemiparesis and right gaze deviation. Initial EMS evaluation revealed a Rapid Arterial oCclusion Evaluation (RACE) score of 7 and a NIHSS of 14. CT head without contrast showed a hyperdense right middle cerebral artery, CT angiogram head confirmed a proximal right M1 occlusion, and CT perfusion revealed a large right hemispheric penumbra.  Risks and benefits of tPA were discussed with the patient’s family and tPA was administered within 95 minutes after last known well. Mechanical thrombectomy was then attempted however on digital subtraction angiography there was complete recanalization of the right middle cerebral artery. Post-procedure MRI brain revealed no acute diffusion restriction. The patient was discharged home with a NIHSS and MRS of 1.

Only 2% of all pediatric strokes are treated with IV-TPA in the USA. Although IV-TPA is not FDA approved for the pediatric population, IV-TPA may be considered in this population after clear discussion of risks and benefits with family.  Ultimately, IV-TPA may help avoid mechanical thrombectomy in these patients.  Furthermore, the presence of a “champagne MRI” in this case illustrates that a “negative MRI” after receiving IV-TPA does not always point to a stroke mimic.  Prospective studies of IV-TPA in the pediatric population are needed as the number of children with ischemic strokes continues to grow.