Search Results (139)

Background/Objectives: Flow diverter stents are widely used for the treatment of complex, unruptured intracranial aneurysms. Nitinol-based devices offer improved flexibility and vessel conformability; however, real-world clinical outcome data remain limited. This study aimed to evaluate the safety and clinical outcomes of nitinol-based flow diverter stents in a single-center cohort. We hypothesized that these devices would demonstrate high technical success rates, low rates of device-related complications, and favorable functional outcomes at 6 months. Methods: We retrospectively analyzed 109 patients with unruptured saccular intracranial aneurysms treated with nitinol-based flow diverter stents between 2020 and 2025. Patients with ruptured aneurysms, non-nitinol devices, or incomplete 6-month follow-up data were excluded. Technical success, device-related complications, and clinical outcomes were assessed using standardized imaging follow-up at 1 month (CT angiography) and 6 months (digital subtraction angiography). Results: Technical success was achieved in 109/109 cases (100%). The internal carotid artery cavernous segment was the most common aneurysm location. Intra- and peri-procedural device-related complications occurred in 12/109 (11%) patients, all of which were successfully managed without permanent neurological deficit. During the 6-month follow-up, post-procedural device-related complications occurred in 5/109 patients (4.6%), all due to delayed stent thrombosis requiring mechanical thrombectomy. One patient died due to persistent stent occlusion, and one patient developed unilateral lower-extremity plegia. Three patients experienced transient, non-device-related hypoesthesia that resolved during follow-up. At 6 months, most patients had favorable functional outcomes, with modified Rankin Scale scores of 0–1. Complete aneurysm occlusion was achieved in 83 of 108 patients (76.9%) at the 6-month angiographic follow-up. Conclusions: Flow diverter stents demonstrated high technical success and favorable clinical outcomes. Fishmouth deformity emerged as a potentially important technical factor associated with thrombotic complications and warrants careful recognition during deployment and follow-up. Full article

Background/Objectives: Carotid revascularization reduces stroke risk in patients with carotid stenosis. Postoperative length of stay (LOS) reflects resource utilization and recovery, yet its determinants remain poorly described in Central Asia. This study examined whether baseline patient characteristics predict prolonged postoperative LOS in a Kazakhstani referral cohort. Methods: We analyzed a single-center retrospective cohort (clinical registry) of 320 consecutive patients who underwent carotid revascularization between January 2018 and December 2025. Carotid endarterectomy (CEA) was performed in 88 patients (27.5%) and carotid artery stenting (CAS) in 228 (71.2%). Prolonged postoperative LOS was defined a priori as >8 days (75th percentile). Multivariable logistic regression was performed, with negative binomial regression; a model additionally including procedure type, and a model including in-hospital complications were used as sensitivity analyses. Results: Patients were predominantly male (74.7%) with a mean age of 71.1 ± 7.5 years and a high burden of comorbidities. Median postoperative LOS was 6 days (IQR 4–8), and 72 patients (22.5%) had prolonged LOS. Postoperative LOS was similar after endarterectomy and stenting (median 6 vs 5 days). In-hospital complications occurred in 11 patients (3.4%), with two deaths (0.6%). No baseline characteristic independently predicted prolonged LOS (all p > 0.05; AUC = 0.629; Hosmer–Lemeshow p = 0.45), and procedure type was not associated with prolonged LOS (adjusted OR 1.14, 95% CI 0.61–2.14). In contrast, in-hospital complications were strongly associated with prolonged LOS (adjusted OR 8.50, 95% CI 2.04–35.40; p = 0.003), although this estimate was imprecise owing to the small number of events. Median postoperative LOS increased from 6 days in patients without complications to 12.5 days in those with complications (p < 0.001). Conclusions: In this elderly, comorbidity-heavy cohort, prolonged postoperative LOS was associated with perioperative complications rather than baseline patient characteristics. Because complications lie on the causal pathway between baseline risk and hospital stay, this finding is best interpreted as hypothesis-generating: it suggests that efforts to shorten stay may be better directed toward complication prevention than preoperative risk stratification, a hypothesis that warrants prospective evaluation. Full article

Background/Objectives: This study aimed to explore whether perioperative changes in cognitive function following carotid artery revascularization, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), are associated with subsequent clinical outcomes, focusing specifically on the Standard Verbal Paired Associate Learning Test (S-PA). Methods: This prospective, single-center study enrolled 69 patients who underwent CEA or CAS between June 2018 and June 2024. Neuropsychological assessments (Raven’s Colored Progressive Matrices (RCPM), Kohs Block Design Test for IQ (Kohs-IQ), the Trail Making Test (TMT)-A/B, and the Standard Verbal Paired Associate Learning Test (S-PA)) were conducted preoperatively and within seven days postoperatively. Patient characteristics and diagnostic imaging results, including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and single-photon emission computed tomography (SPECT), were evaluated. Multivariate Cox proportional hazards models and Kaplan–Meier survival analyses were used to identify predictors of adverse outcomes, defined as recurrent stroke, restenosis, or mortality, during outpatient follow-up. Results: Fifteen patients experienced adverse outcomes during follow-up. Perioperative neuropsychological assessment showed that 36 patients experienced S-PA decline, indicating a tendency towards lower mean cerebral blood flow. Receiver operating characteristic (ROC) curve for perioperative ΔS-PA decline associated with adverse outcomes. The area under the curve (AUC) was 0.728. The optimal cutoff determined by the Youden index was a decline of 2 points (ΔS-PA ≤ −2), yielding a sensitivity of 73.3% and specificity of 68.5%. In a time-to-event analysis, S-PA decline was associated with adverse outcomes in an unadjusted analysis. A similar trend was observed in limited multivariable models; however, effect estimates were imprecise (HR = 4.01, 95% CI: 1.01–15.91, p = 0.048). Conclusions: This study indicates that perioperative decline in S-PA may reflect underlying cerebrovascular vulnerability and may be associated with subsequent adverse outcomes. However, given the limited number of events and potential for residual confounding, these findings should be interpreted with caution. Larger multicenter studies are required to validate these findings. Full article

Background/Objectives: Blunt thoracic aortic injury (BTAI) is a rare, highly lethal trauma typically occurring at the aortic isthmus. Advanced BTAI is primarily treated with thoracic endovascular aortic repair (TEVAR). Because emergent surgical debranching is rarely feasible, management depends heavily on patient anatomy, especially regarding the left subclavian artery (LSA). Patient-specific computational fluid dynamics (CFD) models offer critical insights into periprocedural planning and outcome prediction. Methods: This study investigates hemodynamic changes in a patient-specific BTAI case following intentional LSA coverage by a stent graft. Three-dimensional patient-specific models were coupled with RCR-Windkessel boundary conditions for both pre- and post-procedural imaging data to simulate blood flow in each scenario. Results: Post-intervention, flow distribution improved significantly; relative perfusion to the brachiocephalic trunk and left common carotid artery increased by 3.51% and 4.02%, respectively, alongside an elevated overall pressure throughout the entire computational domain. However, regions with high oscillatory, low magnitude shear (HOLMES), specifically wall areas with values < 0.3 Pa, expanded post-stenting. This warrants careful monitoring during follow-ups, given the associated risk of thrombus formation. Furthermore, time-averaged swirling strength (TASS) variation along the aorta decreased (standard deviation dropped from 1.8610 to 1.3835), indicating stabilized flow within the stented region, while normalized swirling strength increased distally. Conclusions: This study establishes an effective, non-invasive framework for assessing pre- and post-TEVAR hemodynamics. It demonstrates that LSA coverage induces uniformly elevated pressure and alters wall shear stress and helicity indices, highlighting the need for future research into pharmacological management to optimize long-term outcomes. Full article

Symptomatic high-grade carotid stenosis may present with extensive ipsilateral hemispheric hypoperfusion without a large infarct core, a grey-zone phenotype between standard early and truly urgent carotid revascularization. This single-centre retrospective observational study described the procedural and clinical outcomes of urgent carotid revascularization in this imaging-defined subgroup. Consecutive patients treated between June 2015 and August 2025 were included when they had recent ipsilateral anterior-circulation symptoms, ipsilateral internal carotid stenosis > 70%, objective hemispheric hypoperfusion involving at least one third of the anterior circulation territory on CT or MR perfusion, and no intracranial haemorrhage or large established infarction. Twenty-seven patients met the criteria. Median NASCET-style stenosis was 92%, and 14 patients (51.9%) had at least one collateral-limiting feature. Revascularization was performed within 48 h in all cases, by carotid endarterectomy in 25 patients and carotid artery stenting in two. Technical success was 100%. No 30-day death, stroke, intracranial haemorrhage, major adverse event, or target-lesion reintervention occurred. Complete neurological recovery at discharge was observed in 25 patients (92.6%). During median follow-up of 48.6 months, no late ipsilateral stroke, carotid-related neurological event, neurological death, or target-lesion reintervention was recorded. In this small, selected, uncontrolled cohort, urgent carotid revascularization was technically achievable, and no prespecified 30-day safety events were observed. These descriptive findings do not establish comparative safety or clinical benefit and require prospective multicentre validation. Full article

Background: Carotid free-floating thrombus (CFFT) is an uncommon but clinically significant cause of transient ischemic attack and ischemic stroke, carrying a substantial risk of recurrent cerebral embolization. Despite advances in vascular imaging, the optimal management of CFFT remains controversial because available recommendations are largely based on retrospective studies, case series, and expert opinion. The present study reports a single-center experience with CFFT and provides an updated narrative review of current diagnostic and therapeutic strategies, with particular attention to the timing of intervention. Methods: A retrospective review of patients diagnosed with CFFT and managed at our institution over a 20-year period was performed. Clinical presentation, imaging findings, treatment strategy, and outcomes were analyzed. In parallel, a narrative review of the contemporary literature was conducted to summarize current evidence regarding medical management, carotid endarterectomy, endovascular techniques, hybrid approaches, and emerging concepts related to thrombus composition and maturation. Results: Five patients with symptomatic CFFT were identified. Four patients underwent carotid thromboendarterectomy, whereas one patient was managed medically with anticoagulation and antiplatelet therapy, resulting in complete thrombus resolution. Two patients experienced neurological deterioration while receiving initial anticoagulation and subsequently required urgent surgical intervention. No postoperative strokes occurred after carotid endarterectomy. Review of the literature confirmed that anticoagulation remains the cornerstone of initial therapy and achieves thrombus resolution in a substantial proportion of patients. However, recurrent neurological events continue to occur under medical treatment, while the indications and timing of invasive intervention remain poorly defined. Recent advances in high-resolution magnetic resonance imaging and optical coherence tomography suggest that thrombus age and composition may become important determinants of future treatment selection. Conclusions: CFFT represents a rare but potentially unstable vascular condition for which high-quality evidence is still lacking. Initial anticoagulation remains the most widely accepted treatment strategy, while carotid endarterectomy, endovascular thrombectomy, carotid artery stenting, and hybrid procedures may be appropriate in selected patients. Future management algorithms may ultimately move beyond a one-size-fits-all approach by incorporating thrombus biology, imaging characteristics, and individual patient risk profiles. Although this concept remains preliminary, advances in thrombus characterization may provide the foundation for more personalized treatment strategies as further clinical evidence becomes available. Full article

Background and Clinical Significance: Carotid-cavernous fistulas (CCFs) are pathological communications between the carotid artery and the cavernous sinus, most commonly traumatic when direct and high-flow (Barrow type A). Bilateral traumatic CCFs are rare, occurring in approximately 1–2% of cases. Case Presentation: We report a 45-year-old male with polytrauma after a road traffic accident who presented with right-sided chemosis, pulsatile exophthalmos, and ocular bruit. Digital subtraction angiography revealed bilateral direct CCFs. The right fistula was treated with transarterial coil embolization combined with flow-diverter stent placement in the intracavernous internal carotid artery. Subsequent imaging demonstrated left-hemispheric ischemia while the contralateral high-flow CCF remained untreated; the underlying mechanism was considered potentially hemodynamic or thromboembolic. The left fistula was managed using the same technique. Final angiography confirmed complete bilateral occlusion. Despite transient postoperative epistaxis, the patient showed neurological improvement. Conclusions: This case highlights the effectiveness of combined flow diversion and coiling in managing rare bilateral traumatic CCFs. Full article

Background: Arteriovenous fistula is an abnormal connection between an artery and a vein. Post-traumatic fistulas are uncommon and usually occur after penetrating injuries, including gunshot wounds. Cervical arteriovenous fistulas are particularly rare and may coexist with a pseudoaneurysm, creating diagnostic and therapeutic challenges because of the proximity of major vascular, neurological, and aerodigestive structures. In hemodynamically stable patients, the limited external appearance of the wound may underestimate the extent of internal vascular injury; therefore, imaging is central to diagnosis and treatment planning. Case Presentation: We report the case of a 49-year-old man who presented to the emergency department with a gunshot wound to the left side of the neck. Computed tomography angiography (CTA) demonstrated a vascular injury adjacent to the left common carotid artery (LCCA), and further evaluation revealed an arteriovenous fistula (AVF) between the LCCA and the left internal jugular vein (LIJV), coexisting with a pseudoaneurysm of the LCCA. Doppler ultrasonography (DUS) identified an arterial wall defect and extrinsic compression of the LCCA by the hematoma. Selective digital subtraction angiography (DSA) confirmed an AVF between the LCCA and the LIJV, coexisting with an LCCA pseudoaneurysm. A covered stent-graft was implanted and completion angiography confirmed exclusion of both lesions with preserved patency of the LCCA. Discussion: This case demonstrates the complementary value of CTA, DUS and DSA in penetrating neck trauma. CTA provided rapid cross-sectional assessment of the injury trajectory and associated lesions, DUS added information on the arterial wall and local hemodynamic consequences, and DSA confirmed arteriovenous shunting while enabling immediate endovascular treatment. Conclusions: In hemodynamically stable patients with penetrating neck trauma, CTA should be considered when the wound trajectory approaches major vessels, even in the absence of active external bleeding. DUS and DSA may provide complementary information for lesion characterization and procedural planning. Covered stent-graft implantation may be a feasible reconstructive option in carefully selected patients. Full article

Background/Objectives: Patients undergoing carotid revascularization may show distinct patterns of bilateral carotid vulnerability and clinical risk. This study used latent class analysis (LCA) to identify high-resolution magnetic resonance imaging (HR-MRI)-based clinical–radiological phenotypes and evaluate their association with long-term major adverse cardiovascular events (MACE). Methods: This retrospective cohort included 289 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between April 2017 and April 2024 and had preoperative carotid HR-MRI within 90 days. Ipsilateral and contralateral plaque features were assessed on multi-contrast vessel-wall HR-MRI. LCA included five indicators: ipsilateral intraplaque hemorrhage, ipsilateral lipid-rich necrotic core, contralateral intraplaque hemorrhage, cardiovascular disease history, and symptomatic status. MACE comprised cardiovascular death, nonfatal myocardial infarction, coronary revascularization, or stroke. Outcomes were assessed using Kaplan–Meier analysis and multivariable Cox regression. Results: Among 289 patients undergoing carotid revascularization, the mean age was 65.12 ± 9.46 years, and 237 (82.0%) patients were men. LCA identified three phenotypes: Systemic High-Risk (n = 128), Silent High-Risk (n = 37), and Stable/Moderate (n = 124). The Systemic High-Risk phenotype showed high probabilities of symptomatic presentation, cardiovascular disease history, and bilateral carotid vulnerability, whereas the Silent High-Risk phenotype showed marked ipsilateral plaque vulnerability despite lower clinical risk. During a median follow-up of 4.4 years, MACE-free survival differed significantly across phenotypes (log-rank p = 0.043). Compared with the Stable/Moderate phenotype, the Systemic High-Risk and Silent High-Risk phenotypes were both associated with increased MACE risk (HR 1.65, 95% CI 1.15–2.37, p = 0.039; HR 1.43, 95% CI 1.12–2.15, p = 0.034). Conclusions: HR-MRI-based LCA identified clinically meaningful carotid vulnerability phenotypes associated with long-term MACE after carotid revascularization. These findings support integrated assessment of bilateral plaque vulnerability and clinical risk for postoperative cardiovascular risk stratification. Full article

Carotid artery stenting (CAS) is an established revascularization option for patients with carotid disease at high surgical risk. Periprocedural cerebral embolization remains a clinical concern, and plaque prolapse, the extrusion of atherosclerotic material through the stent struts into the lumen, has emerged as an actionable mechanism directly linked to embolic events and adverse neurological outcomes. This narrative review provides a structured, practice-oriented framework addressing one specific question: how can plaque prolapse be prevented during CAS? Drawing on prospective registries, comparative cohort studies and intravascular imaging analyses based on optical coherence tomography (OCT) and intravascular ultrasound (IVUS), we discuss the main determinants of prolapse risk, plaque morphology, procedural variables and device selection, converging on dual-layer micromesh stent (DLMS) technology as the most advanced device-based solution available. Pooled clinical data indicate a 30-day stroke rate of approximately 1.4% when DLMSs are used in combination with embolic protection, and OCT studies confirm reduced prolapse compared with single-layer stents. Prevention requires an integrated strategy combining lesion-specific characterisation, optimised technique and tailored device selection, while standardised imaging definitions and adequately powered randomised trials with hard clinical endpoints remain research priorities. Full article

Background: Hemodynamic depression, characterized by bradycardia and hypotension, is a common complication of carotid artery stenting (CAS) and is primarily attributed to carotid sinus baroreceptor stimulation. While prophylactic atropine is often used in high-risk patients, predictors of unexpected hemodynamic depression among patients initially deemed low-risk remain incompletely defined. Objective: To identify clinical, anatomical, and procedural predictors of hemodynamic depression in patients undergoing CAS without prophylactic atropine. Methods: We performed a retrospective, single-center observational study of consecutive patients undergoing CAS between January 2015 and May 2024. Patients who received prophylactic atropine for low baseline heart rate (HR) were excluded. Hemodynamic depression was defined as a >20% reduction in HR from baseline. Absolute bradycardia (HR <50 bpm) and hypotension (>40% reduction in systolic blood pressure) were recorded descriptively. Results: A total of 158 patients underwent CAS, of whom 33 (20.9%) were excluded due to prophylactic atropine administration for low pre-procedural heart rates (<60 bpm). Among 125 included patients, 62 (49.6%) experienced significant HR reduction during CAS. In multivariable analysis, a shorter distance between the stenotic lesion and the carotid bifurcation was independently associated with hemodynamic depression (OR 0.90 per mm increase; 95% CI 0.82–0.99; p = 0.023). Greater intraprocedural reductions in systolic and mean arterial pressure were also associated with HR depression. Traditional clinical risk factors, including age, sex, comorbidities, degree of stenosis, calcification severity, anesthesia type, and procedure urgency, were not independently predictive. Conclusions: Hemodynamic depression remains frequent during CAS even among patients classified as low risk. Lesion proximity to the carotid bifurcation is a key anatomical predictor of autonomic instability, highlighting the limitations of standard risk stratification and supporting a lesion-specific approach to periprocedural hemodynamic management. Full article

Intraprocedural rupture (IPR) during stent-assisted coiling (SAC) after stent deployment can create a narrow and rapidly changing management problem: hemorrhage control, anticoagulation reversal, acute thrombotic occlusion, and postprocedural cerebrospinal fluid diversion may all become urgent within the same clinical sequence. We report a fatal IPR during SAC of an unruptured anterior communicating artery (AComA) aneurysm and use the case as an anchor for a targeted case-based narrative review. A 71-year-old woman underwent SAC for a 5.1-mm posteriorly directed AComA aneurysm with a bleb after treatment for vertebrobasilar ischemia. Fourth-coil insertion produced tactile resistance and contrast extravasation. Protamine reversal and temporary A1 flow control reduced the leak, but filling defects then developed from the internal carotid artery terminus to the A1 and M1 segments, requiring rescue thrombectomy. Computed tomography showed subarachnoid hemorrhage and intraventricular hemorrhage; same-day progression with hydrocephalus required bilateral external ventricular drainage. The patient died on postoperative day 7. This case highlights IPR during SAC as a time-dependent hemorrhagic–thrombotic escalation rather than a single technical event. We propose a staged assistant–operator communication model for risk mapping, rupture recognition, hemostatic-route preservation, thrombotic surveillance, and transition to computed tomography, external ventricular drainage, and intensive care. Full article

Objective: To evaluate the feasibility and early outcomes of a curvature-guided strategy that guides dual-branch revascularization during Zone 1 Thoracic Endovascular Aortic Repair (TEVAR) based on whether the aortic pathology is predominantly located on the greater or lesser curvature of the arch. Methods: In this retrospective, descriptive study (February 2023–June 2024), 43 consecutive patients were included under a predefined anatomical protocol. Of these, 3 patients (7.0%) were lost to follow-up and were included in the analysis of baseline characteristics and perioperative outcomes. The remaining 40 patients constituted the per-protocol follow-up cohort. Pathologies predominantly on the aortic arch’s greater curvature (n = 21) were managed with a Castor single-branched stent-graft for the left subclavian artery (LSA) and a left common carotid artery (LCCA) chimney stent. Those on the lesser curvature (n = 22) received a physician-modified endograft (PMEG). The primary outcome was technical success; secondary outcomes included safety, branch patency, and reintervention. Results: The overall technical success rate was 97.7% (100% in the Castor-chimney cohort [21/21] vs. 95.5% in the PMEG cohort [21/22]). No perioperative stroke, spinal cord ischemia, or retrograde type A dissection occurred in either cohort. Two type II endoleaks were observed: one intraoperative in the Castor-chimney cohort and one during follow-up in the PMEG cohort. Among the 40 patients (20 per cohort) who completed a median follow-up of 22.5 months, freedom from aortic-related reintervention was 95% (38/40), with one reintervention occurring in each cohort. Branch patency was 100% (20/20) in the PMEG cohort, whereas it was 95% (one asymptomatic LSA occlusion) in the Castor-chimney cohort. Conclusions: The implementation of a curvature-guided protocol, which rationally matches endograft techniques to arch anatomy, suggests acceptable early safety and efficacy for complex Zone 1 TEVAR. This anatomy-driven framework offers a potential personalized approach to dual-branch revascularization and warrants prospective validation. Full article

Background/Objectives: There is no consensus on standardized treatment algorithms for patients with acute ischemic stroke due to anterior circulation tandem occlusions. This study evaluated the outcomes of mechanical thrombectomy and carotid artery stenting in such patients, with a particular focus on a standardized, adaptive, and escalating antithrombotic strategy. Methods: This single-center retrospective study included patients with atherosclerotic tandem occlusion treated between January 2019 and July 2023 at our comprehensive stroke center. All patients underwent mechanical thrombectomy and carotid artery stenting and received a standardized antithrombotic regimen, including the administration of the GPIIb/IIIa antagonist eptifibatide as rescue therapy. Results: Sixty-seven patients were included in the analysis. Thirty-five patients (52.2%) received eptifibatide due to acute stent thrombosis. Subtotal to total revascularization (mTICI 2b-3) was achieved in 98.5% of patients. The carotid artery reocclusion rate was 3.4% at discharge. Symptomatic intracranial hemorrhage occurred more frequently in patients treated with eptifibatide (9.0% vs. 0%, p = 0.021) but was not associated with mortality or favorable outcome (mRS 0–2) at 90 days. In univariable regression analysis, eptifibatide administration was not significantly associated with symptomatic intracranial hemorrhage (OR 1.9, 95% CI 0.3–11.4; p = 0.465). Older age was associated with mortality. Conclusions: Our adaptive antithrombotic protocol demonstrated high revascularization and low carotid reocclusion rates. Rescue use of eptifibatide was not significantly associated with symptomatic intracranial hemorrhage; however, a clinically relevant risk cannot be excluded. These findings highlight the importance of tailored antithrombotic strategies in acute ischemic stroke to maintain stent patency while minimizing hemorrhagic complications. Full article

Background/Objectives: Acute carotid tandem lesions (TLs), defined by concurrent cervical internal carotid artery (ICA) stenosis or occlusion and intracranial large vessel occlusion, occur in 10–20% of patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Optimal periprocedural antiplatelet management during emergent carotid artery stenting (eCAS) remains uncertain, particularly regarding the balance between preventing stent thrombosis and avoiding hemorrhagic complications. Methods: A narrative review was conducted using PubMed and Scopus (until 6 March 2026) to identify English-language studies evaluating antiplatelet therapies during eCAS for TLs. We included seven real-world studies and registry analyses. Data on study design, patient characteristics, procedural strategies, angiographic results, functional outcomes, and safety metrics were extracted. Results: No randomized controlled trials (RCTs) were identified. The available evidence is derived exclusively from observational studies. Across these cohorts, glycoprotein IIb/IIIa inhibitors (GPIs), particularly tirofiban, were generally associated with lower rates of in-stent thrombosis and higher reperfusion success, with symptomatic intracranial hemorrhage (sICH) rates that appeared comparable to or lower than those reported with acetylsalicylic acid (ASA). Cangrelor, an intravenous (IV) P2Y₁₂ inhibitor, was associated with improved stent patency and increased likelihood of complete reperfusion, although reported effects on clinical outcomes were inconsistent when compared with GPIs or ASA. Aside from abciximab, potent IV antiplatelet agents did not consistently show an increased sICH signal. Oral dual antiplatelet therapy was also associated with improved technical outcomes without a clear excess in bleeding complications. Conclusions: Current real-world observational data suggest that rapid-acting IV antiplatelet agents—particularly GPIs and, increasingly, cangrelor—may represent feasible periprocedural options during eCAS for TLs, with potential benefits for technical success and no consistent evidence of increased hemorrhagic risk. However, interpretation is limited by study heterogeneity and non-randomized designs. The absence of RCTs highlights the need for prospective comparative studies and standardized periprocedural antiplatelet protocols. Full article