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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.

Background and Objectives: Although dexmedetomidine (DEX) is widely administered during endovascular treatment (EVT) to enhance procedural adherence of patients with acute ischemic stroke (AIS) with large vessel occlusion, there is limited research on the association of DEX and outcomes among these patients. Hence, this study aimed to explore the safety and outcomes of DEX during conscious sedation (CS) in a real-world setting among patients undergoing EVT., Methods: This study was an individual patient-level pooled analysis of 2 multicenter randomized clinical trials RESCUE-BT and DEVT. This study included patients who underwent EVT because of occlusion of the internal carotid artery or middle cerebral artery. The DEX group included those receiving intraprocedural DEX for CS, whereas the patients without intraprocedural DEX sedation were categorized into the non-DEX group. The primary outcome was functional independence (modified Rankin Scale score of 0-2 at 90 days). Adjusted odds ratio (aOR) and 95% CI were obtained by logistic regression models., Results: A total of 728 patients were included in this study, of whom 308 (42.3%) were female. The median (interquartile range) age was 69 (59-76) years; the median baseline NIH Stroke Scale score was 16 (12-19). Compared with the non-DEX group, the DEX group had a significantly lower rate of functional independence (40.3% vs 51.3%; aOR 0.66; 95% CI 0.46-0.93; p = 0.019). There was a significantly higher rate of unstable procedural hemodynamics in the DEX group (9.7% vs 2.3%; aOR 4.60, 95% CI 2.12-9.99, p < 0.001). In subgroup analysis, similar results were found in intraprocedural DEX-treated patients when compared with local anesthesia or intraprocedural midazolam-treated patients, respectively., Discussion: There was a negative association between procedural DEX administration during CS and functional outcomes in patients with AIS receiving EVT in a real-world setting. A larger cohort is warranted to validate our findings., Classification of Evidence: This study provides Class II evidence that the use of DEX during EVT of AIS is associated with a worse outcome compared with other agents.