PB0275 - Successful off-label use of intra-arterial eptifibatide followed by ticagrelor in a pediatric acute arterial ischemic stroke patient

Background: Standard antiplatelet therapy for pediatric arterial ischemic stroke (AIS) is limited to clopidogrel and acetylsalicyclic acid (ASA). In adult AIS, eptifibatide is used for catheter-directed therapy and ticagrelor is Food and Drug Administration approved for the prevention of recurrent stroke/transient ischemic attack (TIA). We successfully treated a pediatric AIS with eptifibatide and ticagrelor after clinical deterioration despite clopidogrel and ASA therapy.

Aims: To present additional antiplatelet therapy options following pediatric AIS.

Methods: Single subject case report.

Results: A 14-year-old male presented to the ED with left hemiplegia beginning 20 hours prior. Pediatric National Institutes of Health Stroke Scale (PedsNIHSS) was 9 upon arrival and brain magnetic resonance imaging confirmed an acute right middle cerebral artery infarction. Endovascular thrombectomy/thrombolysis was performed, during which the artery was noted to quickly re-occlude. Catheter-directed eptifibatide was successful followed by intravenous eptifibatide. PedsNIHSS post-procedure was 11, 6 after 8 hours, and 4 the next morning. He received 30 hours of eptifibatide drip with one recurrent left hemiplegia episode that resolved within 20 minutes. ASA and clopidogrel were given 4 hours prior to stopping eptifibatide. Five hours after drip stopped, left hemiplegia recurred. Repeat imaging showed no new stroke/extension. Unfractionated heparin (UFH) was added, but stuttering hemiplegia persisted with the last episode lasting over 2 hours. Course suggested clopidogrel and/or ASA clinical resistance. UFH and clopidogrel were discontinued and ticagrelor initiated. No further hemiplegic episodes occurred. P2Y12 platelet reactivity units (PRU) were 33 after 24 hours, indicating successful inhibition. After 10 days, he was discharged on ticagrelor and ASA with a PedNIHSS score of 0 and no evidence of hemorrhagic conversion.

Conclusion(s): We successfully used eptifibatide and ticagrelor in a pediatric AIS case with no adverse events and resolution of stuttering episodes of hemiplegia. Further research into the use of novel antiplatelet agents in the pediatric population is needed.