Acute ischemic stroke in a pediatric patient is a complex disease with a variety of etiologies that differ from adults. Though rare, they are a real phenomenon with potentially devastating consequences. Some treating institutions are using anti-thrombotic drug therapy with unclear benefits. Available literature, which is limited to case reports and retrospective reviews of databases, clouds this topic with both positive and negative outcomes. Emergency department management should focus on stabilization and resuscitation with immediate involvement of a pediatric neurologist and intensivist. The decision to use anti-thrombotic drug therapy, including anti-platelet drugs and thrombolytics, should be in consult with the specialists involved until randomized controlled trials determine their safety and efficacy in the pediatric population.