Rescue Versus First-Line Intracranial Stenting During Thrombectomy for Acute Ischemic Stroke: A Propensity-Weighted Analysis of the RESISTANT Registry

BACKGROUND: While rescue stenting (RS) is a recognized bailout strategy following failed endovascular thrombectomy for acute ischemic stroke with large vessel occlusion, first-line stenting (FLS) has emerged as a potential alternative to avoid vascular injury and improve outcomes. However, direct comparisons between these strategies remain limited. We conducted a comparative analysis of FLS versus RS using data from a large, multicenter international registry to evaluate their relative safety and effectiveness. METHODS: We conducted a comparative analysis of FLS versus RS using data from the RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke), a multicenter, international, retrospective cohort of patients with acute ischemic stroke treated with intracranial stenting during endovascular thrombectomy (2016-2023). Patients were categorized by stenting strategy: FLS (stent placed without prior thrombectomy) or RS (stent placed after failed thrombectomy). The primary effectiveness outcome was functional independence (modified Rankin Scale score, 0-2) at 90 days; the primary safety outcome was symptomatic intracranial hemorrhage. Propensity score inverse probability of treatment weighting was used to adjust for baseline differences. RESULTS: Among 827 patients, 723 were in the RS cohort (median age, 67 [interquartile range, 59-77] years; 64.2% male) and 104 in the FLS cohort (median age, 65.5 [interquartile range, 58.8-77] years; 72.1% male). Using FLS as the reference strategy, inverse probability of treatment weighting-adjusted analyses did not detect significant differences in functional independence (odds ratio [OR], 0.64 [95% CI, 0.38-1.07]) or symptomatic intracranial hemorrhage (OR, 0.93 [95% CI, 0.34-2.59]). No significant differences were observed in secondary outcomes, including successful reperfusion, mortality, or procedural complications. In the anterior circulation cohort (n=589), outcomes were likewise comparable (functional independence: OR, 0.62 [95% CI, 0.60-1.25]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30-2.18]). Similarly, in the posterior circulation cohort (n=234), no significant differences were found (functional independence: OR, 0.82 [95% CI, 0.32-2.10]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30-2.18]). CONCLUSIONS: In this study, no significant differences in safety or effectiveness were detected between FLS and RS strategies during endovascular thrombectomy for acute ischemic stroke. Prospective, randomized trials are needed to better define optimal treatment approaches.