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Updated: Oct 1, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Conservative versus aggressive antiplatelet strategy for emergent carotid stenting during stroke thrombectomy
Raoul Pop1,2,3, François Severac4, Anca Hasiu1
1Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France.
Insights
An aggressive antiplatelet strategy improved carotid stent patency and clinical outcomes in stroke patients undergoing emergent stenting. This approach did not increase risks of mortality or hemorrhagic transformation.
Area of Science:
- Neurology
- Cardiology
- Interventional Radiology
Background:
- Optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy lacks consensus.
- Assessing aggressive versus conservative antiplatelet strategies is crucial for stroke management.
Purpose of the Study:
- To evaluate the safety and efficacy of an aggressive periprocedural antiplatelet strategy.
- To compare this strategy with a conservative approach (aspirin monotherapy) for preserving carotid stent patency.
Main Methods:
- Retrospective analysis of 132 patients undergoing emergent carotid stenting for tandem lesions.
- Comparison of aggressive (dual antiplatelet therapy +/- tirofiban) versus conservative (aspirin monotherapy) antiplatelet strategies.
- Inverse probability of treatment weighting (IPTW) analysis was used for adjusted comparisons.
Main Results:
- Aggressive strategy improved carotid stent patency (aOR 0.23) and moderate clinical outcomes (mRS ≤ 3, aOR 2.72).
- No significant differences were observed in mortality or hemorrhagic transformation rates between groups.
- The aggressive group involved dual antiplatelet therapy (DAPT) in 75.8% and DAPT with tirofiban in 24.1%.
Conclusions:
- Aggressive periprocedural antiplatelet strategy enhances stent patency and clinical outcomes post-carotid stenting.
- This strategy appears safe, with no increased risk of hemorrhagic transformation or mortality.
- Further randomized trials are needed to confirm optimal antiplatelet combinations for acute stroke interventions.
Background:
There is no consensus regarding optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy. We aimed to assess the safety and efficacy of an aggressive periprocedural antiplatelet strategy focused on preserving stent patency, in comparison with conservative antiplatelet strategy consisting of aspirin monotherapy.
Materials And Methods:
Retrospective review of a prospectively collected database in a comprehensive stroke center, including all cases of emergent carotid stenting for tandem lesions stroke between 01.03.2012-01.06.2021. Aggressive antiplatelet strategy consisted of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel loading doses, with added intravenous (IV) tirofiban if in-stent thrombosis was observed during thrombectomy. Clinical and radiological outcomes were compared between conservative and aggressive antiplatelet treatment groups using inverse probability of treatment weighting (IPTW) analysis based on propensity scores.
Results:
We included 132 cases (76.5% atheroma, 22.7% dissection, 0.7% carotid web). Forty-five patients (34%) cases received conservative antiplatelet therapy. The remaining 87 (65.9%) received aggressive antiplatelet therapy: 66 (75.8%) treated with DAPT, 21 (24.1%) with DAPT and tirofiban. Periprocedural heparin was avoided in all cases. In adjusted analysis of the weighted samples, aggressive antiplatelet strategy was associated with improved carotid stent patency (aOR 0.23, 95% CI 0.07-0.80, p = 0.021), higher proportion of moderate clinical outcome (mRS ≤ 3, aOR 2.72, 95% CI 1.01-7.30, p = 0.04), with no significant differences in mortality and hemorrhagic transformation (HT) rates.
Conclusions:
In this retrospective study, aggressive periprocedural antiplatelet strategy led to improved stent patency and clinical outcomes, without increased HT. Further prospective randomized research is warranted to identify the optimal combination of antiplatelet agents for emergent carotid stenting in the setting of acute stroke.
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