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Introduction Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder. Ischemic stroke is a known manifestation, but large vessel occlusions (LVOs) are rare and challenging to manage due to resistance to standard therapies. We report the first documented use of eculizumab to prevent reocclusion of an LVO in an APS patient.Abstract C121 Figure 1Case Description A 50-year-old woman with known APS presented with stroke in progress and acute neurological deterioration. Imaging showed an occlusion of the distal left internal carotid artery (ICA). Emergency thrombectomy and stenting achieved only partial reperfusion. Within 24 hours, the stent reoccluded. Due to rapid failure and the prothrombotic state, the stent was removed endovascularly, and maximal medical therapy was initiated. Plasma exchange was considered but contraindicated because of a subarachnoid hemorrhage. Antiplatelet therapy with cangrelor was ineffective, even at adjusted doses. Given ongoing thrombosis and suspected complement activation, eculizumab was initiated. The patient stabilized without further thrombotic events. A 4-week follow-up black-blood MRI showed no vessel wall contrast enhancement, indicating resolution of inflammation.Abstract C121 Figure 2Conclusions This case demonstrates the difficulty of treating LVOs in APS, where endovascular approaches may fail due to poor response to antiplatelet agents. In this patient, cangrelor was ineffective, and reocclusion occurred rapidly after stenting. Complement inhibition with eculizumab proved successful and well-tolerated. Medical therapy may be preferable over endovascular treatment in APS patients with refractory thrombosis, especially when standard antithrombotic strategies are ineffective or contraindicated.Abstract C121 Figure 3Conflict of Interest No