Safety and efficacy of intravenous thrombolytics among patients with emergent intracranial stenting after thrombectomy: Subanalysis of the RESISTANT registry

Background: The value of intravenous thrombolysis (IVT) prior to endovascular therapy (EVT) with emergent stenting for intracranial atherosclerotic disease (ICAD)-large vessel occlusion (LVO) is unknown. We aimed to investigate the safety and efficacy of IVT among patients with adjuvant intracranial stenting after EVT. Methods: RESISTANT is a study of consecutive acute ischemic stroke patients who underwent EVT and intracranial stenting from 36 comprehensive stroke centers in 7 countries across 3 continents. The primary outcome of interest was ordinal shift of the modified Rankin Scale (mRS) score at 90 days after the intervention. Secondary outcomes were excellent outcome (mRS 0–1) and functional independence (mRS 0–2) at 90 days. Safety outcomes were rates of symptomatic intracranial hemorrhage (sICH) at 24-hour and 90-day mortality. Adjusted multivariate ordinal and logistic regressions were performed for all outcomes. Results: Of 828 patients (median age 67 years, interquartile range (IQR) 59–77; 65% male), 23% have received IVT. In the adjusted analysis, receiving IVT was not associated with mRS ordinal shift (aOR 0.8, 95% CI 0.6 -1.1), nor with functional independence (aOR 1.1, 95% 0.7–1.7). However, there was a positive association with excellent outcome (aOR 1.6, 95% CI 1.0–2.7). There were no differences in sICH rates at 24-h (aOR 1.5, 95% CI 0.8–2.9), nor 90-day mortality (aOR 0.8, 95% 0.5–1.3). Conclusion: In this multi-center study of patients who underwent EVT with emergent intracranial stenting, IVT was associated with excellent clinical outcome, possibly due to indication bias, and there were no safety concerns. Receiving IVT should not be a criterion for deferring acute stenting among patients with ICAD-associated LVO and IVT should not be routinely withheld in suspected ICAD cases.