(922) Tenecteplase and Mechanical Thrombectomy in a Six-Year-Old Patient With Acute Ischemic Stroke

Introduction: Pediatric acute ischemic stroke (AIS) is rare, 1 to 2 per 100,000 cases annually. Current evidence regarding the management of pediatric AIS is limited, with adult studies being used to make informed treatment decisions. Case reports have demonstrated successful outcomes from alteplase; however, none have reported use of tenecteplase despite its increasing use in adult stroke. Tenecteplase is a modified form of tissue plasminogen activator with higher fibrin specificity and reduced rate of clearance from plasma, simplifying administration to one bolus dose compared to alteplase’s initial bolus followed by a 1-hour infusion.

Description: A 6-year-old female with a history of type 1 diabetes and atrial septal defect status post catheter device closure in 2022, presented to the emergency department with acute onset right-sided weakness, aphasia, and facial droop starting 50 minutes prior. Her vital signs were significant for hypertension 128/72 mmHg and tachycardia of 103. Her serum glucose was 440 mg/dL. Magnetic Resonance Angiography showed severe stenosis/occlusion of the left carotid terminus with decreased distal blood flow, diminutive left M1 and M2 segments, and a relative paucity of M3 cortical vasculature on the left. She received tenecteplase 0.25 mg/kg intravenously 3 hours after symptom onset. A follow-up computed tomography was negative for bleed. She underwent a right transfemoral cerebral angiogram and mechanical thrombectomy of the left carotid to ramus occlusion with significant improvement and return of distal blood flow through the MI and A2 segments and small residual occlusion of the A2 segment. Anticoagulation therapy was initiated 48 hours post procedure. Serum glucose levels were controlled. Clinically, she showed significant improvement with resolution of her symptoms apart from slight right sided facial droop.

Discussion: The simplified dosing for tenecteplase offers an advantage in the thrombolytic portion of AIS management, reducing logistical challenges for pediatric centers unfamiliar with stroke protocol and simplifying transfers. The safety and dosing profile remain nebulous with no investigation in pediatrics completed, however, our experience describes one of the first successful uses of tenecteplase in a child at a dose of 0.25 mg/kg without complication.