Effect of periprocedural antithrombotic medication on functional outcome and symptomatic intracranial hemorrhage in patients with carotid tandem lesions.

BACKGROUND: Up to 15% of patients with acute ischaemic stroke, eligible for endovascular treatment (EVT), have a carotid tandem lesion (TL) of atherosclerotic origin; defined as an extracranial carotid artery stenosis of ≥50% or occlusion with an intracranial large vessel occlusion. The optimal periprocedural antithrombotic (AT) management is unclear for this subgroup. OBJECTIVE: This post-hoc analysis of the MR CLEAN-MED randomised multicentre clinical trial (ISRCTN76741621) evaluated the effect of various periprocedural AT regimens on outcomes in TL patients. METHODS: TL patients randomised in the MR CLEAN-MED trial were included. Good functional outcome (GFO) was defined as modified Rankin Scale score of 0-2 at 90 days. Symptomatic intracranial haemorrhage (sICH) was classified according to the Heidelberg criteria. Outcomes were compared by AT regimen (aspirin, heparin or both aspirin and heparin) using logistic regression, adjusted for baseline variables. RESULTS: Between 22 January 2018 and 27 January 2021, 628 patients were included, of which 100 had a TL. Among 76 patients receiving AT, 26 (34.2%) achieved GFO, versus 14/24 (60.9%) without AT (adjusted OR (aOR) 0.79, 95% CI 0.63 to 0.99). Rates of GFO were comparable across regimens; 30.4% with aspirin (aOR 0.82, 95% CI 0.61 to 1.11), 29.2% with heparin (aOR 0.75, 95% CI 0.57 to 0.99) and 41.4% with both (aOR 0.81, 95% CI 0.62 to 1.06).sICH occurred in 15.8% of AT treated patients versus 4.4% without AT (OR 4.31, 95% CI 0.53 to 35.02). By regimen, sICH rates were 17.4% with aspirin, 16.7% with heparin and 13.8% with both. CONCLUSION: In TL patients undergoing EVT, periprocedural AT was associated with worse functional outcome and there was a numerically higher rate of sICH; however, this association was not statistically significant and the estimate was imprecise.