Dual antiplatelet therapy in pediatric neurointerventional procedures: a retrospective case series

OBJECTIVE: Pediatric neurointerventional procedures are uncommon and management protocols are often extrapolated from adult data. In adults, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the standard of care to reduce thromboembolic events following placement of a stent or flow diverter. There is limited evidence regarding the safety and efficacy of DAPT in the pediatric population and its use remains off-label. The aim of this study was to evaluate the safety and efficacy of DAPT in children undergoing neurointerventional procedures. METHODS: This single-center retrospective case series included pediatric patients (age ≤ 18 years) who underwent a neurointerventional procedure and received DAPT during a continuous period between 2016 and 2024. Data on patient demographics, procedural details, antiplatelet regimens, and clinical outcomes were collected. The primary outcomes were the incidence of thrombotic events (e.g., stroke and in-stent thrombosis) and major bleeding complications. RESULTS: Fifteen patients (10 male, median age 12 years) were included in this analysis. Indications included arterial aneurysms (n = 8) and venous sinus stenosis (n = 6). All patients received DAPT and aspirin, while 13 received clopidogrel and 4 received ticagrelor (2 patients received both). No thromboembolic complications, strokes, or device thromboses occurred (0/15, 95% CI 0.0%-21.8%). One patient (1/15, 95% CI 0.2%-31.9%) experienced a significant retroperitoneal hemorrhage, which was likely related to vascular access and was medically managed. No other major adverse events were reported. CONCLUSIONS: In this case series, DAPT was well tolerated and appeared effective in preventing thromboembolic complications in pediatric patients after neurointerventional surgery. These findings support the use of DAPT in this population, although further prospective studies are needed to establish evidence-based guidelines for optimal dosing, timing, and duration of therapy.