Context: Based on current literature, there is no consensus regarding the proper emergency management of Pediatric Acute Ischemic Stroke (P-AIS). In other words, there are lots of considerable controversies in this regard. Therefore, the current review was conducted to provide a more comprehensive discussion on this topic. 
Evidence Acquisition: The search was conducted using the terms “pediatrics”, “stroke”, and “recombinant tissue plasminogen activator” in the PubMed database. English papers on the management of P-AIS published after 2000 were selected. An expert panel performed a critical appraisal to summarize the findings and make them applicable. Finally, the extracted data were categorized under proper subheadings, and the manuscript was prepared.
Results: The related papers provided limited evidence on this topic. All extracted findings were categorized as follows: etiology and the underlying diseases, clinical presentations, diagnosis, management (thrombolytic therapy and thrombectomy), and outcome.
Conclusions: Although thrombolytic therapy is recommended in P-AIS, most cases are diagnosed outside the therapeutic window, so P-AIS is practically impossible, and they are candidates for mechanical interventions. On the other hand, the proper device may not be available to fit the size of the younger children’s vasculature.