Abstract WP055: Safety and Efficacy of Periprocedural Antithrombotics in Endovascular Stroke Treatment: A Systematic Review and Network Meta-Analysis

Introduction: Acute ischemic stroke due to large-vessel occlusion remains a major cause of disability and mortality. Periprocedural antithrombotic therapy during endovascular stroke treatment may enhance outcomes but increases bleeding risk. We systematically evaluated the safety and efficacy of these agents in acute stroke patients. Methods: Comprehensive search across PubMed, Embase, Scopus, and Google Scholar from inception through June 2025. Included RCTs and cohorts comparing periprocedural antithrombotics versus no therapy/alternatives in adults ≥18 years with acute ischemic stroke undergoing mechanical thrombectomy. Primary outcomes include symptomatic intracranial hemorrhage (sICH), functional independence (mRS 0-2) at 90 days. Secondary outcomes include successful reperfusion (TICI 2b-3), mortality, and complications. Meta-analysis used R 4.5.1 with random/fixed-effects models. Risk of bias was assessed using Cochrane RoB 2.0 and Newcastle-Ottawa Scale. Protocol registered on PROSPERO (CRD420251129943). Results: Twenty-five studies encompassing 26,300 patients were analyzed following PRISMA 2020 guidelines. Analysis revealed that periprocedural antithrombotic therapy significantly increased sICH (log OR: 0.28, 95% CI: 0.11-0.44, p=0.0008) but found no significant difference in the odds of achieving an mRS score of 0-2 (log OR: -0.13, 95% CI: 0.30-0.03, p=0.1195). Secondary outcomes revealed substantial negative effects with all-cause mortality at 90 days being significantly increased (log OR: 0.23, 95% CI: 0.07-0.38, p=0.0057), but TICI 2b-3 was markedly improved (log OR: 0.18, 95% CI: 0.04-0.33, p=0.0143). In the Network meta-analysis, both NOAC (p=0.0186) and VKA (p=0.0025) showed a significant positive effect on functional independence. Conversely, VKA was associated with a significant increase in all-cause mortality (p<0.0001), and UFH with more procedure-related complications (p=0.0083). Conclusion: This analysis, integrating both paired and network meta-analysis data, reveals a complex profile of antithrombotic therapies. While some treatments show clear benefits, such as NOAC and VKA improving functional independence, significant safety concerns were identified, such as an increase in sICH and mortality, highlighting the need for a personalised approach in periprocedural antiplatelet selection, carefully weighing the potential for efficacy against the risk of adverse outcomes.