Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy

Cerebrovasc Dis. 2021;50(2):162-170. doi: 10.1159/000512204. Epub 2021 Jan 20.


Background: While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates.

Methods: We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded.

Results: Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213).

Conclusion: AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.

Keywords: Acute ischemic stroke; Antiplatelet therapy; Carotid artery stenosis; Carotid artery stenting; Cerebral hemorrhage; Endovascular stroke therapy; Interventional neuroradiology; Intracerebral hemorrhage; Intravenous thrombolysis; Treatment of acute stroke.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Carotid Stenosis / diagnostic imaging
  • Carotid Stenosis / therapy*
  • Cerebral Hemorrhage / chemically induced*
  • Cerebral Hemorrhage / diagnostic imaging
  • Dual Anti-Platelet Therapy / adverse effects*
  • Emergencies
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / instrumentation
  • Female
  • Humans
  • Male
  • Middle Aged
  • Platelet Aggregation Inhibitors / adverse effects*
  • Registries
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Stents
  • Stroke / diagnostic imaging
  • Stroke / therapy*
  • Thrombectomy* / adverse effects
  • Thrombolytic Therapy* / adverse effects
  • Time Factors
  • Tirofiban / adverse effects
  • Treatment Outcome


  • Platelet Aggregation Inhibitors
  • Tirofiban