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Introduction/Purpose Pediatric traumatic cerebrovascular injury is rare but can result in substantial morbidity and mortality. Emergent stenting may be required to preserve perfusion but demands immediate, reliable platelet inhibition to maintain stent patency. This presents a major antiplatelet management challenge as oral P2Y12 inhibitors may be unreliable or unsafe in settings of polytrauma, hemorrhagic risk, or need for repeated surgery. Cangrelor, an intravenous P2Y12 antagonist with rapid onset and offset, offers a titratable and reversible alternative. While cangrelor has shown promise in adult neurointervention, pediatric neurotrauma experience is exceedingly limited and, to our knowledge, confined to a single prior case report. We present three adolescents with traumatic internal carotid artery (ICA) injuries treated with cangrelor as an adjunct or bridge, with platelet reactivity unit (PRU)-guided management and outcomes.Materials and Methods We retrospectively reviewed three adolescents (ages 14-17) with traumatic ICA injuries who underwent urgent endovascular reconstruction at a single pediatric center (2024-2025). Injuries included petrous ICA pseudoaneurysm after blunt trauma, penetrating cervical ICA pseudoaneurysm/dissection, and traumatic ICA occlusion with thrombus from skull base fracture. Interventions included flow-diverting stent placement, covered stent reconstruction, and balloon angioplasty with self-expanding carotid stent. Cangrelor was administered peri-procedurally and/or as a bridge during interruption of oral P2Y12 therapy. Infusions ranged from 0.25-0.75 mcg/kg/min, with selective bolus dosing, and were titrated to PRU targets generally between 100-200, with higher targets used perioperatively or during increased bleeding risk. PRU and hematologic parameters guided dose adjustment and transition to aspirin plus an oral P2Y12 inhibitor.Results Cangrelor achieved timely platelet inhibition in all cases without in-stent thrombosis, ischemic stroke, or major hemorrhage attributable to antiplatelet therapy. Antiplatelet coverage was maintained during a high-risk perioperative course that included external ventricular drainage with subsequent ventriculoperitoneal shunt and gastrostomy placement, open neck exploration/ligation for expanding hematoma, and facial fracture fixation. Stent patency was confirmed by early and follow-up imaging (days 6-7 and day 44 or 3 months). Transitions to oral dual antiplatelet therapy occurred without gaps. One patient had no neurological deficits at discharge; the remaining two had persistent deficits attributable to the index traumatic injuries rather than stent-related thromboembolic complications, including diffuse spasticity after severe traumatic brain injury and cranial nerve VI palsy with decreased visual acuity after skull base trauma.Conclusion Although limited to three patients, our experience aligns with adult data and supports cangrelor’s feasibility as an adjunct or bridge in acute pediatric neurointervention when oral P2Y12 inhibitors are not feasible or must be held. Multicenter or prospective studies are needed to define optimal dosing, monitoring, and perioperative management in this population.Disclosures C. Trujillo: None. B. Lee: None. J. McGrath: None. S. Larson: None. A. Ahmed: None.