Recent changes in practice recommendations for adult acute AIS support mechanical thrombectomy up to 24 hours after last normal in patients meeting specific clinical and radiographic criteria. A lack of randomized, controlled trials in childhood acute AIS limits development of guidelines for treatment with thrombolysis or thrombectomy.

Describe clinical characteristics and presentation timeline of a single-center cohort of children with acute arterial ischemic stroke (AIS) potentially eligible for hyperacute stroke treatment.

113 children with AIS age 30 days-18 years were included in a prospectively-enrolled, consecutive cohort from 2005-2017. Exclusions included insufficient presentation timeline data or delay in diagnosis >2 weeks. A stroke database and charts were reviewed. Pediatric NIH Stroke Scale (PedNIHSS) scores were abstracted from medical records or scored retrospectively.

Mean age at presentation was 8.9 years (80% >2 years, 37% female). 25% were in-hospital strokes. Common risk factors were intracranial vasculopathy in 43 (38%) and cardiac disease in 24 (21%). Of the 69 patients who presented within 4 hours of stroke onset, 56 were >2 years, 19 of those 56 had a PedNIHSS score 6-24, and 7 of those 19 had no medical contraindication to IV-tPA. Four received IV-tPA. Of the 77 patients who presented within 6 hours, 52 were >3 years, 17 of whom had a PedNIHSS score 6-24. Two patients had a mechanical thrombectomy. Of the 94 patients who presented within 24 hours, 65 were >3 years old, 20 of whom had a PedNIHSS score 6-24.

Young age, delay to presentation, and medical contraindication to IV-tPA represent significant barriers to hyperacute intervention in childhood AIS. Twenty-six patients >3 years old had PedNIHSS scores qualifying for potential thrombectomy, but only 17 presented within 6 hours, our current institutional guideline for potential mechanical thrombectomy. Despite challenges, opportunities exist deserving further study to improve acute care in childhood AIS.