Radiographic Bleeding Risk After Carotid Stenting for Stroke: Eptifibatide and a Predictive Score

Introduction: Antiplatelet therapy is essential for stent patency in acute ischemic stroke (AIS) patients receiving internal carotid artery stents. Half-dose eptifibatide is used for emergent stenting in severe presentations. This study evaluates the bleeding risk associated with eptifibatide+dual antiplatelet therapy (DAPT) versus DAPT and introduces a clinical risk score for radiographic intracerebral hemorrhage (ICH).


Methods: This single center, retrospective cohort study (June 2017–June 2024) included adults with AIS who underwent internal carotid artery stenting and received eptifibatide+DAPT versus DAPT alone. The primary outcome was symptomatic ICH (NIHSS worsening > 4). Due to low event rates, radiographic ICH was used for multivariable modeling. Secondary endpoints included 30-day ischemic stroke, in-hospital mortality, and stent restenosis. A ridge-penalized logistic regression was used to identify predictors of radiographic ICH and develop a risk score.


Results: Among 176 patients, 52 received eptifibatide+DAPT and 124 patients received DAPT. Eptifibatide was administered for a median of 18.2 hours. The eptifibatide+DAPT group had higher stroke severity (NIHSS 14.4 vs 9.3, p< 0.001), underwent thrombectomy more often (69% vs 27%), and had a greater frequency of high-grade stenosis (62% vs 33%). Symptomatic ICH was rare and not significantly different between groups (1.9% vs 4.0%, p=0.804). Radiographic ICH occurred more frequently with eptifibatide (38.5% vs 12.9%, p< 0.001) and provided sufficient events for multivariable analysis. Ridge regression identified eptifibatide use (OR ~3.2) and NIHSS (OR ~2.3 per point) as the strongest predictors of radiographic ICH, followed by stenosis >90% and diabetes. A point-based score was derived: 2 points for NIHSS ≥15, 2 for eptifibatide use, 1 for diabetes, and 1 for high-grade stenosis. Patients with scores of 0–1 had ~5% risk of radiographic ICH, compared to 45% in those scoring ≥3.


Conclusions: Eptifibatide was associated with increased radiographic but not symptomatic ICH. This bleeding risk appeared linked to higher stroke severity and more urgent intervention in the eptifibatide+DAPT group. A risk score may help guide individualized antiplatelet decisions during emergent carotid stenting.