Intravenous Cangrelor Versus Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Endovascular Thrombectomy for Middle Cerebral Artery Stroke: A Multi-Institutional Propensity Score-Matched Analysis

BACKGROUND: Antiplatelet therapy is frequently used during endovascular thrombectomy (EVT) for middle cerebral artery (MCA) stroke, particularly when intracranial stenting is required. This study compared clinical outcomes between intravenous cangrelor and glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing EVT for MCA stroke. METHODS: Using the TriNetX research network (113 healthcare organizations), we identified adult patients with MCA stroke who underwent EVT between January 2016 and January 2026 and received concomitant cangrelor or GPIs. Propensity score matching (1:1) was performed to balance baseline characteristics. Primary outcomes included major bleeding, intracranial hemorrhage (ICH), and decompressive hemicraniectomy. Prespecified subgroup analysis stratified patients by adjunctive angioplasty/stenting. RESULTS: After matching, 302 patients remained in each group. In the overall cohort, no significant differences were observed in major bleeding (18.9% vs 24.5%; HR 0.74, P=0.084), ICH (17.9% vs 22.5%; HR 0.77, P=0.14), or mortality (17.2% vs 14.9%; HR 1.13, P=0.55). However, in the angioplasty/stenting subgroup (n=98 per group), cangrelor appeared to be associated with lower rates of major bleeding (15.3% vs 26.5%; HR 0.53, 95% CI 0.28-1.01, P=0.047), ICH (14.3% vs 25.5%; HR 0.52, P=0.04), decompressive hemicraniectomy (17.3% vs 31.6%; HR 0.52, P=0.02), and functional dependency (18.4% vs 31.6%; HR 0.50, P=0.02), but higher recurrent stroke at 1-24 months (32.7% vs 11.2%; HR 2.57, P<0.01). No difference in outcomes was found in the no angioplasty group. CONCLUSIONS: Both drugs demonstrated comparable outcomes overall. In an exploratory angioplasty/stenting subgroup, cangrelor was associated with reduced hemorrhagic complications but increased recurrent stroke, suggesting a complex risk-benefit tradeoff requiring individualized antiplatelet selection.