Interaction of Intraprocedural Antiplatelets and Intravenous Thrombolysis in Acute Intracranial Stenting: RESISTANT Registry Subanalysis

INTRODUCTION/OBJECTIVE: Acute intracranial stenting during endovascular thrombectomy (EVT) for ischemic stroke requires intraprocedural antiplatelet therapy (APT) to maintain patency. However, the hemorrhagic risk of combining APT with intravenous thrombolysis (IVT) remains uncertain. We evaluated the safety of IVT combined with conservative versus aggressive intraprocedural APT in patients requiring stenting during EVT. METHODS: This multicenter RESISTANT registry subanalysis (2016-2023) included 823 adults. APT was categorized as conservative (aspirin +/- oral P2Y12) or aggressive (including GPIIb/IIIa inhibitors or cangrelor). The primary outcome was a composite of symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma (PH1/PH2). Multivariable logistic regression assessed associations and interactions between IVT and APT. RESULTS: A total of 823 patients were included: 44 (5.3%) received IVT + conservative APT, 130 (15.8%) No IVT + conservative APT, 145 (17.6%) IVT + aggressive APT, and 504 (61.2%) No IVT + aggressive APT. Frequencies of sICH-PH1-PH2 were 9.3% with IVT + conservative APT, 10.7% with IVT + aggressive APT, 3.2% with No IVT + conservative APT, and 9.9% with No IVT + aggressive APT. In multivariable analysis without interaction terms, neither IVT (aOR 1.18, 95% CI 0.58-2.27; p = 0.64) nor aggressive APT (aOR 2.10, 95% CI 0.92-5.69; p = 0.10) was independently associated with increased risk of sICH-PH1-PH2. However, in the interaction model, IVT within the conservative-APT stratum (aOR 5.84, 95% CI 1.07-43.92; p = 0.05) and aggressive APT within the no-IVT stratum (aOR 4.81, 95% CI 1.41-30.22; p = 0.03) were each associated with higher odds of sICH-PH1-PH2, while the IVT-by-APT interaction term was < 1 (aOR 0.15, 95% CI 0.02-0.94; p = 0.05), indicating attenuation of the joint effect on the multiplicative odds scale. CONCLUSION: Among patients requiring intracranial stenting during EVT, we found no evidence that IVT and aggressive intraprocedural APT act synergistically to increase hemorrhagic risk. Rather, the negative IVT-by-APT interaction suggested attenuation of the joint effect on the multiplicative odds scale, although patients receiving both therapies remained at increased hemorrhagic risk relative to the reference group.

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Journal
Annals of Clinical and Translational Neurology
Published
2026-06-09
DOI
https://doi.org/10.1002/acn3.70449
Primary Topic
Acute Ischemic Stroke Management
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article
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article

Interaction of Intraprocedural Antiplatelets and Intravenous Thrombolysis in Acute Intracranial Stenting: RESISTANT Registry Subanalysis

Andrea Salcuni, N. Abdelhakim, Manuel Requena, Torcato Meira et al.
Annals of Clinical and Translational Neurology
Acute Ischemic Stroke Management
article

Interaction of Intraprocedural Antiplatelets and Intravenous Thrombolysis in Acute Intracranial Stenting: RESISTANT Registry Subanalysis

Andrea Salcuni, N. Abdelhakim, Manuel Requena, Torcato Meira, Alessandro Pedicelli, Nikolaos Ntoulias, Shadi R. Yaghi, Stefano Molinaro, Catarina Perry da Câmara, Adnan Mujanović, Eric Kontowicz, Jérémy Hofmeister, David Seoane, Vinay Jaikumar, Elena Zapata‐Arriaza, Zehra Uysal Kocabaş, Aarón Rodríguez-Calienes, Serdar Geyik, Anderson Brito, João André Sousa, José Rodríguez Castro, Sadiq Al Salman, Gonzalo de Paco, Jose Amorim, Asier de Albóniga-Chindurza, Pedro Vega, Manuel Moreu, Alicia Sierra, Francesca Richetti, Fabio Gomes, Eduardo Bárcena-Ruiz, J Marto, Thanh N. Nguyen, Samantha Miller, Alejandro Tomasello, Alfonso López‐Frías, Adnan Siddiqui, Mariano Velo, Dileep R. Yavagal, Johannes Kaesmacher, Ameer E. Hassan, Mariangela Piano, Isabel Fragata, Luis Albuquerque, Piers Klein, Marc Ribo, Francesco Capasso, Juan F. Arenillas, Jude H. Charles, Amedeo Cervo, Francesco Diana, Daniele Romano, Luca Scarcia, Andrea Alexandre, Songul Senadim, Erwah Kalsoum, Michele Romoli, Jane Khalife, Mohamad Abdalkader, Santiago Ortega‐Gutierrez, Stanislas Smajda, Marta Olivé‐Gadea, Tudor G. Jovin, Pedro Navia, Paolo Machi, Pedro Castro, João Sargento‐Freitas, Mauro Bergui, Marios Psychogios, Leonardo Cruz‐Criollo, Joaquín Zamarro, Mohammad AlMajali, Atilla Özcan Özdemir, Francesco Biraschi, Leonardo Renieri, Yazan Ashouri
article en

Abstract

INTRODUCTION/OBJECTIVE: Acute intracranial stenting during endovascular thrombectomy (EVT) for ischemic stroke requires intraprocedural antiplatelet therapy (APT) to maintain patency. However, the hemorrhagic risk of combining APT with intravenous thrombolysis (IVT) remains uncertain. We evaluated the safety of IVT combined with conservative versus aggressive intraprocedural APT in patients requiring stenting during EVT. METHODS: This multicenter RESISTANT registry subanalysis (2016-2023) included 823 adults. APT was categorized as conservative (aspirin +/- oral P2Y12) or aggressive (including GPIIb/IIIa inhibitors or cangrelor). The primary outcome was a composite of symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma (PH1/PH2). Multivariable logistic regression assessed associations and interactions between IVT and APT. RESULTS: A total of 823 patients were included: 44 (5.3%) received IVT + conservative APT, 130 (15.8%) No IVT + conservative APT, 145 (17.6%) IVT + aggressive APT, and 504 (61.2%) No IVT + aggressive APT. Frequencies of sICH-PH1-PH2 were 9.3% with IVT + conservative APT, 10.7% with IVT + aggressive APT, 3.2% with No IVT + conservative APT, and 9.9% with No IVT + aggressive APT. In multivariable analysis without interaction terms, neither IVT (aOR 1.18, 95% CI 0.58-2.27; p = 0.64) nor aggressive APT (aOR 2.10, 95% CI 0.92-5.69; p = 0.10) was independently associated with increased risk of sICH-PH1-PH2. However, in the interaction model, IVT within the conservative-APT stratum (aOR 5.84, 95% CI 1.07-43.92; p = 0.05) and aggressive APT within the no-IVT stratum (aOR 4.81, 95% CI 1.41-30.22; p = 0.03) were each associated with higher odds of sICH-PH1-PH2, while the IVT-by-APT interaction term was < 1 (aOR 0.15, 95% CI 0.02-0.94; p = 0.05), indicating attenuation of the joint effect on the multiplicative odds scale. CONCLUSION: Among patients requiring intracranial stenting during EVT, we found no evidence that IVT and aggressive intraprocedural APT act synergistically to increase hemorrhagic risk. Rather, the negative IVT-by-APT interaction suggested attenuation of the joint effect on the multiplicative odds scale, although patients receiving both therapies remained at increased hemorrhagic risk relative to the reference group.

Annals of Clinical and Translational Neurology
Boston University (US), University of Messina (IT), University of Iowa (US), Boston Medical Center (US), Université Paris-Est Créteil (FR), Universidad Científica del Sur (PE), Brown University (US), Policlinico Umberto I (IT), Hospital Universitario La Paz (ES), Cooper University Hospital (US), University Hospital of Bern (CH), University Hospital of Basel (CH), Agostino Gemelli University Polyclinic (IT), Jackson Memorial Hospital (US), Hospital Clínico San Carlos (ES), Hospital de São João (PT), Centre Hospitalier Universitaire Henri-Mondor (FR), Azienda Ospedaliera Citta' della Salute e della Scienza di Torino (IT), Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (IT), Unidade Local de Saúde de São José (PT), Hospital Universitario 12 De Octubre (ES), University Hospital of Geneva (CH), Hospital de Egas Moniz (PT), Ospedale “M. Bufalini” di Cesena (IT), Azienda Ospedaliero-Universitaria Careggi (IT), Fondation de Rothschild (FR), Vall d'Hebron Hospital Universitari (ES), Bon Secours Mercy Health (US), Hôpitaux Universitaires Henri-Mondor (FR), Valley Baptist Medical Center (US), Instituto de Biomedicina de Sevilla (ES), Hospital Universitario Central de Asturias (ES), Ospedali Riuniti San Giovanni di Dio e Ruggi d'Aragona (IT), Hospital Braga (PT), Jacobs Institute (US), Hospital Universitario Virgen de la Arrixaca (ES), Cooper University Health Care (US), Hospital Clínico Universitario de Valladolid (ES), Eskişehir Osmangazi University (TR), Geneva College (US), University at Buffalo, State University of New York (US), Istanbul University (TR), University of Coimbra (PT)
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