The incidence of pediatric stroke is 1.29-13.0 per 100,000 annually. Use of fibrinolytic therapy in qualified adults with acute ischemic stroke is standard practice. However, alteplase is not recommended in pediatric patients. Case: We report a case of a 16 year old Caucasian female who presented to the emergency room with aphasia and right arm numbness one hour and twenty minutes after symptom onset. National Institutes of Health Stroke Scale (NIHSS) was three. Initial computed tomography

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... ut contrast showed a hyper-dense left middle cerebral artery (MCA). The patient was below the minimum age for alteplase administration in acute ischemic stroke. Written consent was obtained from the parents and 90 mg alteplase (0.9 mg/kg; 90 mg maximum) was administered 3 h 25 min after symptom onset. Right arm numbness resolved thirty minutes after drug administration and repeat NIHSS was one for mild expressive aphasia. Diffusion-weighted MRI the following day demonstrated infarction of the posterior left insular cortex while sparing most of the MCA distribution. She remained stable during hospitalization and was discharged home on daily aspirin and resumed school activities with full recovery. Discussion: Although stroke is among the top ten causes of mortality in this age group, there are many barriers to administration of alteplase. Use of alteplase in the pediatric population is poorly reported and there are no randomized trials conducted in this age group. Due to the challenges in conducting randomized controlled trials in children, registries provide an alternative approach to gathering and analyzing information. Clinicians are encouraged to continue reporting cases of alteplase use in pediatric stroke patients.