Safety and Functional Outcomes of Reperfusion Therapies in Pediatric Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Arterial ischemic stroke (AIS) is not common in pediatric patients; however, it causes significant morbidity and mortality. Reperfusion therapies, including intravenous thrombolysis (IVT) and endovascular mechanical thrombectomy (EVT) are established standards of care in selected adults with acute ischemic stroke; however, their safety and functional outcomes in the pediatric population remain poorly defined. Objective: To assess the safety and functional outcomes of reperfusion therapies in children with AIS. Methods: A systematic search was conducted across major databases including PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane Library. Studies reporting on pediatric patients aged 18 years or less treated with IVT, EVT, or both for acute AIS were included. The primary safety outcome was the risk of developing symptomatic intracerebral hemorrhage (sICH). Primary functional outcomes were 90-day functional independence, measured via the Pediatric Modified Rankin Scale (Ped-mRS ≤ 2) or Pediatric Stroke Outcome Measure (PSOM ≤ 1). Secondary outcomes measured included successful recanalization (Modified Thrombolysis in Cerebral Ischemia [mTICI] grade 2b/3), and death due to any cause at 90 days. Results: Successful angiographic recanalization evaluated across thrombectomy and bridging arm cohorts revealed high success rate with the pooled proportion of 87.4% (95% CI: 79.1–93.9%). Reperfusion therapies are associated with significant early neurological recovery and favorable 90-day functional outcomes (Ped-mRS 0–2 achieved in a substantial majority of treated cohorts), when compared to the best medical treatment (BMT) controls. The overall rate of sICH remains low (<2%), demonstrating a much better safety profile comparable to adult benchmarks. Conclusions: Acute reperfusion therapies in pediatric AIS are associated with high rates of recanalization and favorable functional outcomes and had low observed rates of symptomatic intracranial hemorrhage in selected pediatric observational cohorts. However, given the absence of randomized controlled trials, these findings reflect observational associations and must be interpreted with appropriate clinical caution. Therefore, there is need for further prospective international studies capable of generating higher-quality evidence to guide future pediatric stroke management.