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Background: The present study aimed to evaluate the efficacy and safety of intravenous tirofiban versus alteplase before endovascular treatment (EVT) in acute ischemic stroke patients with intracranial large vessel occlusion., Methods: This was a post hoc analysis using data from 2 multicenter, randomized trials: the DEVT trial (Direct Endovascular Treatment for Large Vessel Occlusion Stroke) from May 2018 to May 2020 and the RESCUE BT trial (Intravenous Tirofiban Before Endovascular Thrombectomy for Acute Ischemic Stroke) from October 2018 to October 2021. Patients with acute intracranial large vessel occlusion within 4.5 hours from last known well were dichotomized into 2 groups: tirofiban plus EVT versus alteplase bridging with EVT. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 3-month mortality. Multivariable logistic regression (adjusting for baseline systolic blood pressure, occlusion site, onset-to-puncture time, anesthesia, and first choice of EVT) and propensity score overlap weighting (balance in demographic covariates, stroke characteristics, and initial management between groups) were performed., Results: One-hundred and eighteen alteplase-treated patients in the DEVT trial and 98 tirofiban-treated patients in the RESCUE BT trial were included (median age, 70 years; 115 [53.2%] men). The rate of functional independence was 60.2% in the tirofiban group compared with 46.6% in the alteplase group (adjusted odds ratio, 1.25 [95% CI, 0.60-2.63]). Compared with alteplase, tirofiban was not associated with increased risk of symptomatic intracranial hemorrhage (6.8% versus 9.2%; P =0.51) and mortality (17.8% versus 19.4%; P =0.76). The propensity score overlap weighting analyses showed consistent outcomes., Conclusions: Among patients with intracranial large vessel occlusion within 4.5 hours of onset, tirofiban plus EVT was comparable to alteplase bridging with EVT regarding the efficacy and safety outcomes. These findings should be interpreted as preliminary and require confirmation in a randomized trial., Registration: URL: https://www.chictr.org.cn; Unique identifiers: ChiCTR-IOR-17013568 and ChiCTR-INR-17014167., Competing Interests: Disclosures Dr Nguyen reports being an associate editor for Stroke; compensation from Brainomix for the advisory board; compensation from Idorsia for the advisory board; pilot grant to her institution from the Society of Vascular and Interventional Neurology; compensation from Medtronic USA, Inc, for consultant services; and being a principal investigator for Route 92 Medical, Inc (no compensation). Dr Saver reports compensation from BrainQ for consultant services; stock options in Rapid Medical; stock options in Neuronics Medical; compensation from CSL Behring for consultant services; compensation from Biogen for consultant services; compensation from Roche for consultant services; compensation from Boehringer Ingelheim (prevention only) for consultant services; compensation from Abbott Laboratories for consultant services; compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; compensation from BrainsGate for consultant services; compensation from Aeromics for consultant services; stock options in MindRhythm; compensation from MIVI Neuroscience for data and safety monitoring services; and compensation from Medtronic USA, Inc, for consultant services. Dr Nogueira reports stock options in Corindus, Inc; compensation from Viz AI for consultant services; compensation from Synchron for data and safety monitoring services; compensation from Anaconda Biomed for consultant services; stock holdings in Quantanosis AI; stock options in Brainomix; compensation from NeuroVasc Technologies, Inc, for consultant services; compensation from Ceretrieve for consultant services; compensation from Imperative Care, Inc, for consultant services; compensation from Phenox, Inc, for consultant services; compensation from Brainomix for consultant services; compensation from Philips for consultant services; compensation from RapidPulse for consultant services; compensation from Cerenovus for consultant services; compensation from Hybernia for consultant services; stock options in Truvic; compensation from Brainomix for consultant services; compensation from Perfuze for consultant services; compensation from Genentech for consultant services; compensation from Stryker Corporation for consultant services; compensation from Prolong Pharmaceuticals for consultant services; compensation from Corindus Vascular Robotics for consultant services; stock options in Vesalio; compensation from Cerebrotech for consultant services; compensation from RapidPulse for consultant services; stock options in Reist/Q’Apel Medical; compensation from Astrocyte for consultant services; stock options in Perfuze; compensation from Genentech for consultant services; compensation from Phenox for consultant services; compensation from Stryker for consultant services; stock options in Viseon, Inc; compensation from Vesalio for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Anaconda for consultant services; compensation from Cerenovus for consultant services; stock options in Viz AI; stock options in Perfuze; compensation from Imperative Care for consultant services; compensation from Biogen, Inc, for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Vesalio for consultant services; stock options in Cerebrotech; grants from Cerenovus; compensation from Viz AI for consultant services; stock options in Ceretrieve; compensation from Biogen, Inc, for consultant services; stock options in Viz AI; stock holdings in Brain4Care; grants from Stryker; compensation from Ceretrieve for consultant services; stock holdings in Piraeus Medical; compensation from Shanghai Wallaby for consultant services; compensation from Perfuze for consultant services; compensation from Corindus, Inc, for consultant services; and compensation from Prolong Pharmaceuticals for consultant services. The other authors report no conflicts.

Aims: This study aimed to evaluate the association between stress hyperglycemia ratio (SHR) and clinical outcomes at 90 days in acute ischemic stroke due to large vessel occlusion receiving endovascular treatment., Methods: The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial, consisting of 948 stroke patients from 55 centers in China. A total of 542 patients with glucose and glycated hemoglobin (HbA1C) values at admission were included in this analysis. SHR, measured by glucose/HbA1C, was evaluated as both a tri-categorical variable (≤1.07 vs. 1.08-1.29 vs. ≥1.30) and a continuous variable. The primary outcome was a favorable functional outcome (modified Rankin Scale [mRS] score ≤2) at 90 days. The secondary outcome included excellent functional outcome (mRS score ≤1) and safety outcomes, such as 90-day mortality and intracranial hemorrhage. The study was registered with Chictr.org.cn (ChiCTR-INR-17014167)., Results: Compared with patients in the lowest tertile of SHR, the highest tertile group had significantly lower odds of achieving favorable functional outcome of mRS score of 0-2 (adjusted odds ratio, 0.44; 95% confidence interval, 0.28-0.69; p < 0.001) and excellent clinical outcome of mRS score of 0-1 (adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.79; p = 0.004) at 90 days after adjusting for potential covariates. Similar results were observed after further adjustment for preexisting diabetes and Alberta Stroke Program Early Computed Tomography Score (ASPECTS)., Conclusion: Stress hyperglycemia ratio, as measured by the glucose/HbA1C, was associated with a decreased odds of achieving a favorable functional outcome in patients with acute large vessel occlusion stroke at 90 days., (© 2023 The Authors. CNS Neuroscience & Therapeutics published by John Wiley & Sons Ltd.)

Background: The effect of imaging selection paradigms on endovascular thrombectomy outcomes in patients with acute ischemic stroke with large vessel occlusion remains uncertain. The study aimed to assess the effect of basic imaging (noncontrast computed tomography with or without computed tomographic angiography) versus advanced imaging (magnetic resonance imaging or computed tomography perfusion) on clinical outcomes following thrombectomy in patients with stroke with large vessel occlusion in the early and extended windows using a pooled analysis of patient-level data from 2 pivotal randomized clinical trials done in China., Methods: This post hoc analysis used data from 1182 patients included in 2 multicenter, randomized controlled trials in China that evaluated adjunct therapies to endovascular treatment for acute ischemic stroke (Direct Endovascular Treatment for Large Artery Anterior Circulation Stroke performed from May 20, 2018, through May 2, 2020, and Intravenous Tirofiban Before Endovascular Treatment in Stroke from October 10, 2018, through October 31, 2021). Patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery (M1/M2 segments) were categorized according to baseline imaging modality (basic versus advanced) as well as treatment time window (early, 0-6 hours versus extended, 6-24 hours from last known well to puncture). The primary outcome was the proportion of patients with functional independence (modified Rankin Scale score of 0-2) at 90 days. Multivariable Poisson regression analysis was performed to determine the association between imaging selection modality and outcomes after endovascular treatment at each time windows., Results: A total of 1182 patients were included in this cohort analysis, with 648 in the early (471 with basic imaging versus 177 advanced imaging) and 534 in the extended (222 basic imaging versus 312 advanced imaging) time window. There were no differences in 90-day functional independence between the advanced and basic imaging groups in either time windows (early window: adjusted relative risk, 0.99 [95% CI, 0.84-1.16]; P =0.91; extended window: adjusted relative risk, 1.00 [95% CI, 0.84-1.20]; P =0.97)., Conclusions: In this post hoc analysis of 2 randomized clinical trial pooled data involving patients with large vessel occlusion stroke, an association between imaging selection modality and clinical or safety outcomes for patients undergoing thrombectomy in either the early or extended windows was not detected. Our study adds to the growing body of literature on simpler imaging paradigms to assess thrombectomy eligibility across both the early and extended time windows., Registration: URL: http://www.chictr.org.cn; Unique identifiers: ChiCTR-IOR-17013568 and ChiCTR-INR-17014167., Competing Interests: Disclosures Dr Nogueira reports consulting fees for advisory roles with Anaconda Biomed, Biogen, Cerenovus, Corindus, Imperative Care, Medtronic, Genentech, NeuroVasc Technologies, Perfuze, Phenox, Prolong Pharmaceuticals, RapidPulse, Stryker, Vesalio, and Viz-AI, and stock options for advisory roles with Brainomix, Ceretrieve, Corindus, Perfuze, Vesalio, and Viz-AI, and receiving grants from Cerenovus, and Stryker. Dr Saver reports consulting fees for advisory roles with Biogen, Boehringer Ingelheim (prevention only), BrainQ, BrainsGate, Johnson & Johnson Health Care Systems Inc, Medtronic USA, Roche, and stock options for advisory roles with MindRhythm, Neuronics Medical, and Rapid Medical, and Data And Safety Monitoring fee from MIVI Neuroscience. Dr Nguyen reports research support from Medtronic/SVIN; advisory board Idorsia (unrelated). The other authors report no conflicts.

Background and Objective: To investigate the efficacy and safety of IV infusion of tirofiban before endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerotic disease. The secondary objective was to identify potential mediators for the clinical effect of tirofiban., Methods: Post hoc exploratory analysis of the Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, which was a randomized, double-blinded, placebo-controlled trial at 55 centers in China from October 2018 to October 2021. Patients with occlusion of the internal carotid artery or middle cerebral artery due to intracranial atherosclerosis were included. The primary efficacy outcome was the proportion of patients achieving functional independence (defined as modified Rankin scale 0-2) at 90 days. Binary logistic regression and causal mediation analyses were used to estimate the treatment effect of tirofiban and the potential mediators., Results: This study included 435 patients, of whom 71.5% were men. The median age was 65 (interquartile range [IQR] 56-72) years, with a median NIH Stroke Scale of 14 (IQR 10-19). Patients in the tirofiban group had higher rates of functional independence at 90 days than patients in the placebo group (adjusted odds ratio 1.68; 95% CI 1.11-2.56, p = 0.02) without an increased risk of mortality or symptomatic intracranial hemorrhage. Tirofiban was associated with fewer thrombectomy passes (median [IQR] 1 [1-2] vs 1 [1-2], p = 0.004), which was an independent predictor of functional independence. Mediation analysis showed tirofiban-reduced thrombectomy passes explained 20.0% (95% CI 4.1%-76.0%) of the effect of tirofiban on functional independence., Discussion: In this post hoc analysis of the RESCUE BT trial, tirofiban was an effective and well-tolerated adjuvant medication of endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerosis. These findings need to be confirmed in future trials., Trial Registration Information: The RESCUE BT trial was registered on the Chinese Clinical Trial Registry: chictr.org.cn, ChiCTR-INR-17014167., Classification of Evidence: This study provides Class II evidence that tirofiban plus endovascular therapy improves 90-day outcome for patients with large vessel occlusion due to intracranial atherosclerosis., (© 2023 American Academy of Neurology.)

BACKGROUND AND OBJECTIVE: To investigate the efficacy and safety of IV infusion of tirofiban before endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerotic disease. The secondary objective was to identify potential mediators for the clinical effect of tirofiban. METHODS: Post hoc exploratory analysis of the Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, which was a randomized, double-blinded, placebo-controlled trial at 55 centers in China from October 2018 to October 2021. Patients with occlusion of the internal carotid artery or middle cerebral artery due to intracranial atherosclerosis were included. The primary efficacy outcome was the proportion of patients achieving functional independence (defined as modified Rankin scale 0-2) at 90 days. Binary logistic regression and causal mediation analyses were used to estimate the treatment effect of tirofiban and the potential mediators. RESULTS: This study included 435 patients, of whom 71.5% were men. The median age was 65 (interquartile range [IQR] 56-72) years, with a median NIH Stroke Scale of 14 (IQR 10-19). Patients in the tirofiban group had higher rates of functional independence at 90 days than patients in the placebo group (adjusted odds ratio 1.68; 95% CI 1.11-2.56, p = 0.02) without an increased risk of mortality or symptomatic intracranial hemorrhage. Tirofiban was associated with fewer thrombectomy passes (median [IQR] 1 [1-2] vs 1 [1-2], p = 0.004), which was an independent predictor of functional independence. Mediation analysis showed tirofiban-reduced thrombectomy passes explained 20.0% (95% CI 4.1%-76.0%) of the effect of tirofiban on functional independence. DISCUSSION: In this post hoc analysis of the RESCUE BT trial, tirofiban was an effective and well-tolerated adjuvant medication of endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerosis. These findings need to be confirmed in future trials. TRIAL REGISTRATION INFORMATION: The RESCUE BT trial was registered on the Chinese Clinical Trial Registry: chictr.org.cn, ChiCTR-INR-17014167. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that tirofiban plus endovascular therapy improves 90-day outcome for patients with large vessel occlusion due to intracranial atherosclerosis.