Aggressive versus Conventional Antiplatelet Therapy During Emergent Carotid Stenting in Acute Ischemic Stroke:...

The optimal antiplatelet regimen during emergent carotid artery stenting in acute ischemic stroke remains uncertain. Aggressive strategies may improve stent patency but could increase hemorrhagic risk.

We conducted a multicenter observational study including patients with tandem occlusion or isolated involvement of extracranial internal carotid artery treated with emergent carotid artery stenting ± mechanical thrombectomy between 2019 and 2023 across eight comprehensive stroke centers. Two intraprocedural antiplatelet approaches were compared: conventional (aspirin or none) versus aggressive (glycoprotein IIb/IIIa inhibitors or clopidogrel ± aspirin) Primary outcomes were early stent occlusion (≤48h), symptomatic intracranial hemorrhage, and good functional outcome at 90 days (modified Rankin Scale 0-2).

Among 309 patients (mean age 67.2 years; 69.6% male), 95 (31%) received aggressive therapy and 209 (69%) conventional treatment. Early stent occlusion occurred in 9/283 (3.2%) patients, with no significant difference between groups (4.5% vs 2.6%; p=0.38). Symptomatic intracranial hemorrhage was observed in 18 patients (5.9%), similarly distributed (4.2% vs 6.7%; p=0.39). At 90 days, 54.8% achieved modified Rankin Scale 0-2; unadjusted analysis suggested higher rates with aggressive therapy (64.4% vs 50.3%; p=0.03), but this association was not confirmed after multivariable adjustment. Intravenous thrombolysis and successful recanalization were independent predictors of good outcome, while procedural duration predicted early stent occlusion.

Aggressive antiplatelet therapy during emergent carotid artery stenting was not associated with reduced early stent occlusion or improved functional outcomes, nor with an increased risk of symptomatic intracranial hemorrhage. Procedural factors appear more influential than pharmacological intensity. Randomized trials are warranted to define optimal strategies.