Catastrophic Pediatric Stroke Following Attempted Transcatheter Ventricular Septal Defect Closure

BACKGROUND: Periprocedural stroke is a rare but potentially catastrophic complication of pediatric cardiac catheterization. CASE SUMMARY: An 18-month-old girl with a perimembranous ventricular septal defect and progressive aortic valve prolapse underwent elective transcatheter closure. The procedure was abandoned after 2 unsuccessful device deployment attempts due to worsening aortic regurgitation and device instability. Two hours later, she developed acute neurological deterioration. Brain computed tomography demonstrated a large right hemispheric infarction combining mixed-density subdural collection, and uncal herniation. Emergency decompressive craniectomy with hematoma evacuation was performed. Evaluation for thrombophilia and coagulopathy was negative. DISCUSSION: Thromboembolism related to subtherapeutic anticoagulation, contrast-related neurotoxicity, and patient vulnerability in the setting of procedural complexity were considered the most plausible mechanism. TAKE-HOME MESSAGE: Strict anticoagulation monitoring, appropriate heparin dosing, careful contrast selection, and thoughtful patient selection are essential to improve the safety of pediatric transcatheter interventions.