Periprocedural Antiplatelet Therapy Before Mechanical Thrombectomy for Acute Ischemic Stroke: a Network Meta-Analysis of Randomized Controlled Trials
Savio Batista1, Raphael Camerotte2, Marina Vilardo3, Christian Fukunaga4, Lucas Mitre5, Rodrigo Twardowski Scherer6, Pedro Borges7, Társis C. Mendes8, Ocilio Goncalves8, Ana Santos9, Anthony Hong9, Dominique Montecino10, Bruna Leles V. de Souza11
1Department of Neurology, Emory University, 2Faculty of Medicine, Federal University of Rio de Janeiro, 3Faculty of Medicine, Catholic University of Brasilia, 4FMABC University Center, 5Santa Casa de São Paulo School of Medical Sciences, 6Pontifical Catholic University of Rio Grande do Sul, 7Department of Neurosurgery, University of Pennsylvania, 8Federal University of Piauí, 9University of Costa Rica, 10Department of Neurology, Mayo Clinic, 11Department of Neurology, Massachusetts General Hospital
Objective:
To assess the efficacy and safety of periprocedural antiplatelet therapy in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS) based on a network meta-analysis of randomized controlled trials (RCTs).
Background:
Antiplatelet therapy (APT) plays a crucial role in stroke prevention, but its role in the periprocedural period of MT is less clear. Existing trials have explored the benefits of antiplatelets, including tirofiban, in conjunction with MT. However, there is a lack of comprehensive comparison across trials evaluating their potential in preventing platelet aggregation and reducing reocclusion during MT.
Design/Methods:
A systematic search following PRISMA guidelines was performed across PubMed, Embase, Cochrane, and Web-of-Science for RCTs comparing antiplatelets before or during MT with no drug/placebo in AIS. Efficacy outcomes were functional independence at 90 days (modified Rankin Scale 0-2) and successful reperfusion (extended Thrombolysis in Cerebral Infarction score ≥2b). Safety outcomes were mortality at 90 days and symptomatic intracranial hemorrhage (sICH). We used frequentist network meta-analysis model, reporting odds ratios (ORs) with 95% confidence intervals (CIs).
Results:
Three RCTs (1,696 patients; median age 67 [27-86] years, 55.9% male) were included. Functional independence did not significantly differ between treatment groups. Compared to placebo, aspirin (OR 1.25, 95% CI 0.30-5.12) and tirofiban (OR 2.00, 95% CI 0.68-5.88) showed higher but not statistically significant rates of successful reperfusion. Aspirin demonstrated a higher rate of sICH (OR 2.07, 95% CI 1.21-3.52), while tirofiban did not significantly differ (OR 1.50, 95% CI 1.00-2.54). Mortality rates also did not differ statistically between approaches.
Conclusions:
Periprocedural aspirin may potentially increase the rates of sICH without offering substantial benefits in efficacy outcomes. Tirofiban might have efficacy and safety outcomes similar to placebo. Our findings are limited by the small number of RCTs analyzing this intervention. Future trials are necessary to optimize patient selection for this approach and strengthen the evidence level.
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