Safety of emergent carotid stenting after thrombolysis: a multicenter retrospective matched analysis

Purpose: Mechanical thrombectomy (MT) with emergent carotid artery stenting (eCAS) has been suggested to provide greater benefits for patients with tandem lesions (TL), but there is uncertainty about the most appropriate peri-procedural antiplatelet therapy for patients at higher risk of brain hemorrhage. This study aimed to assess the safety of intravenous thrombolysis (IVT) in patients with acute TL undergoing MT with eCAS. Methods: The databases of 17 stroke centers were retrospectively screened for consecutive patients with acute TL who underwent MT and eCAS. Propensity score matching (PSM) was used to evaluate the safety of IVT, balancing for peri-procedural antiplatelet therapies. Primary outcome measures were the occurrence of parenchymal hemorrhage (PH) type 2 and mortality within 90 days from the index event. Secondary outcome measures included occurrence of PH type 1, extracranial bleeding events, early stent thrombosis, efficient recanalization after MT and the 90-day functional outcome. Results: Among 560 enrolled patients, 47.3% received IVT prior to the endovascular procedure. After PSM, there was no significant difference between patients treated with and without IVT under different antiplatelet regimens concerning the rates of PH type 2 (5.2% versus 6.9%, p = 0.7, respectively) and of mortality of any cause (7.5% vs. 8.2%, p = 0.8). In addition, IVT did not impact recanalization rates or clinical outcome. Conclusions: The safety of MT with eCAS in acute TL is not affected by prior IVT. Furthermore, IVT does not ameliorate recanalization rates and clinical outcome. These findings are exploratory and require validation through future randomized controlled studies.