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Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients

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Abstract

Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0–2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20–2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09–1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39–2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12–16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07–5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2–16.28; p = 0.026). No differences were noted for mRS 0–2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs.

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Data Availability

Data will be made available upon reasonable request to the corresponding author.

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Acknowledgements

We would like to acknowledge the following people for their contribution: Kathie Gonzales, CRA, University of Iowa Hospitals and Clinics.

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Authors and Affiliations

  1. Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Mudassir Farooqui, Milagros Galecio-Castillo, Darko Quispe-Orozco, Cynthia B. Zevallos, Aaron Rodriguez-Calienes, Juan Vivanco-Suarez & Santiago Ortega-Gutierrez

  2. Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA

    Afshin A. Divani & Asad Ikram

  3. Department of Neurology, Valley Baptist Medical Center / University of Texas Rio Grande Valley, Harlingen, TX, USA

    Ameer E. Hassan & Wondewossen G. Tekle

  4. Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA

    Mouhammad A. Jumaa & Syed F. Zaidi

  5. Department of Neurology, Hospital Vall d’Hebron, Barcelona, Barcelona, Spain

    Marc Ribo & Federica Rizzo

  6. Department of Neurology, University of Kansas Medical Center, Kansas, KS, USA

    Michael Abraham & Tiffany Barkley

  7. Department of Neurology, Yale University School of Medicine, New Haven, CT, USA

    Nils Petersen

  8. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Johanna Fifi & Reade De Leacy

  9. Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA

    Waldo R. Guerrero & Maxim Mokin

  10. Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA

    Amer M. Malik & Dileep R. Yavagal

  11. Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA

    James E. Siegler & Jane Khalife

  12. Cooper Medical School of Rowan University, Camden, NJ, 08103, USA

    James E. Siegler & Jane Khalife

  13. Department of Neurology, Boston Medical Center, Boston, USA

    Thanh N. Nguyen & Mohamad Abdalkader

  14. Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA

    Sunil A. Sheth & Sergio Salazar-Marioni

  15. Texas Stroke Institute, Dallas-Fort Worth, Forth Worth, TX, USA

    Albert J. Yoo & Jazba Soomro

  16. Department of Neurology, Saint Louis University, St. Louis, MO, USA

    Guillermo Linares & Weston Gordon

  17. Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA

    Nazli Janjua & Charoskhon Turabova

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  1. Mudassir Farooqui
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  2. Afshin A. Divani
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  3. Milagros Galecio-Castillo
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  14. Sunil A. Sheth
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  15. Albert J. Yoo
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  18. Darko Quispe-Orozco
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  19. Asad Ikram
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  20. Wondewossen G. Tekle
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  21. Syed F. Zaidi
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  22. Cynthia B. Zevallos
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  23. Federica Rizzo
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  26. Jane Khalife
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  27. Mohamad Abdalkader
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  28. Sergio Salazar-Marioni
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  29. Jazba Soomro
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  30. Weston Gordon
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  31. Aaron Rodriguez-Calienes
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  32. Juan Vivanco-Suarez
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  33. Charoskhon Turabova
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  34. Maxim Mokin
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  35. Dileep R. Yavagal
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  36. Santiago Ortega-Gutierrez
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Contributions

SOG, MF, MGC, DQO: concept and study design, data collection, statistical analysis, writing, revision manuscript; AI, WGT, SFZ, FR, TB, RDL, JK, MA, SSM, JS, WG, ARC, JVS, CT, MM, DRY, CBZ: data collection; AD, AEH, MAJ, MR, MA, NP, JF, WRG, AMM, JES, TNN, SAS, AJY, GL, NJ: critical review, revision manuscript.

Corresponding author

Correspondence to Santiago Ortega-Gutierrez.

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Competing Interests

Dr Ortega-Gutierrez is a consultant for Medtronic and Stryker Neurovascular and received grants from NIH-NINDS (R01NS127114-01, R03NS126804), Stryker, Medtronic, Microvention, Penumbra, IschemiaView, Viz.ai, and Siemens. Dr. Divani received the following support: the University of New Mexico Center for Brain Recovery and Repair Center of Biomedical Research Excellence through Grant Number (NIH P20GM109089, W81XWH-17–2-0053, and 1R21NS130423-01. Dr. Sheth reports consultancy fees from Penumbra, Imperative Care and Viz.AI. Dr. Sheth reports grant funding and support from the NIH (R01NS121154). The other authors do not report competing interests.

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Farooqui, M., Divani, A.A., Galecio-Castillo, M. et al. Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients. Transl. Stroke Res. (2023). https://doi.org/10.1007/s12975-023-01214-9

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