2026 Southeastern Residency Conference

Background: Tirofiban is an intravenous glycoprotein IIb/IIIa inhibitor used after intracranial stenting procedures to reduce the risk of thrombotic complications. However, tirofiban is associated with an increased risk of bleeding, including intracranial hemorrhage (ICH). Balancing thrombotic prevention with bleeding risk remains a challenge in patients undergoing intracranial stent placement. Obesity may influence the safety and effectiveness of antiplatelet therapies due to alterations in drug distribution. Data evaluating tirofiban use in obese patients who have undergone intracranial stenting procedures is limited. Specifically, the impact of obesity on major bleeding and treatment failure outcomes has not been well studied. The purpose of this study is to compare the incidence of intracranial hemorrhage or stent reocclusion, between obese and non-obese patients receiving tirofiban after intracranial stenting procedures. 
Methods: This retrospective chart review included adult patients (≥18 years) who underwent elective or emergent intracranial stenting and received intravenous tirofiban during hospitalization at a comprehensive stroke center between July 1, 2018, and June 30, 2025. Patients were grouped based on body mass index (BMI) into obese (BMI ≥30 kg/m²) and non-obese (BMI <30 kg/m²) groups.  The primary outcome was treatment failure, defined as a composite outcome of intracranial hemorrhage or stent reocclusion confirmed by imaging during the hospitalization. The secondary outcome was major bleeding, defined by the International Society on Thrombosis and Haemostasis (ISTH) criteria as fatal bleeding, bleeding in critical areas, a drop in hemoglobin of ≥2 g/dL, or leading to a transfusion of ≥2 units of blood. Data collected included demographic characteristics, BMI, relevant comorbidities, indication for the procedure, tirofiban dosing and duration, renal function, and concomitant antiplatelet or anticoagulant therapy. Outcomes were assessed during the tirofiban infusion only. Baseline characteristics were summarized, and outcomes were compared between groups using t-tests, chi-square analysis, or Fisher’s exact test. 
Results: A total of 101 patients were included in the analysis, with 59 non-obese and 42 obese patients. Obese patients were younger (54.9 ± 15.1 vs 63.8 ± 14.7 years, p=0.007) and had higher creatinine clearance values (137.4 ± 75.4 vs 85.7 ± 36.5 mL/min, p<0.0001) compared to non-obese patients. As expected, obese patients had significantly higher dosing and actual body weights and received larger tirofiban loading doses. Other baseline characteristics, including sex, severity scores (Hunt & Hess, NIHSS), duration of tirofiban infusion, overlap with oral antiplatelet therapy, and renal dose adjustments, were similar between groups. The primary composite outcome of ICH or stent reocclusion occurred in 30.5% of non-obese patients and 40.5% of obese patients (p=0.299). Major bleeding occurred in 32.2% of non-obese patients compared to 42.9% of obese patients (p=0.273). Rates of individual outcomes, including ICH (22.0% vs 38.1%, p=0.079) and stent reocclusion (11.9% vs 2.4%, p=0.071), were not significantly different between groups. There was no significant difference in major bleeding when comparing severely obese patients (BMI ≥40 kg/m²) to non-severely obese patients (33.3% vs 37.1%, p=0.245). 
Conclusions: In this retrospective analysis, obesity was not associated with a statistically significant increase in treatment failure or major bleeding among patients receiving tirofiban following intracranial stenting. However, numerically higher rates of intracranial hemorrhage were observed in obese patients, suggesting a potential safety signal. Given the overall high bleeding risk and lack of obesity-specific dosing guidance, caution remains warranted, and larger, prospective studies are needed to better define optimal dosing strategies and bleeding risk in this population.

Comparing Tenecteplase and Alteplase for Acute Ischemic Stroke: A Real-World Evaluation of Efficacy and Safety  
Catherine Wise, Katleen Chester, Olivia Morgan, Morgan Daniel; Grady Memorial Hospital, Atlanta, Georgia 
Background: 
Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. Intravenous fibrinolytics have been the standard of care for AIS for decades, with alteplase historically being the fibrinolytic of choice, however, there is an expanding body of evidence supporting tenecteplase as a safe and effective alternative fibrinolytic. Tenecteplase is a genetically modified variant of alteplase, with increased fibrinogen binding specificity and extended half-life. Unlikealteplase, which has continuous infusions, tenecteplase is administered as a single intravenous bolus, offering practical advantages such as greater workflow efficiency and rapid treatment initiation, leading to shorter door-to-needle (DTN) times, which may translate to improved reperfusion and patient outcomes. Clinicaltrials, including the EXTEND-IA TNK trial further reported improved reperfusion rates when tenecteplase was administered prior to thrombectomy compared with alteplase. The AcT trial further demonstrated that tenecteplase achieves comparable rates of early recanalization and functional recovery, as assessed by the modified Rankin Scale (mRS). Observational cohort studies suggest real-world benefits, including shorter DTN and door-to-puncture (DPT) times. This study aims to further evaluate tenecteplase and alteplase in real-world practice, with an emphasis on safety and efficacy, to assess potential to enhance stroke care and optimize patient recovery within a high-volume comprehensive stroke center. 
Methods: 
This is a single-center retrospective chart review of patients who presented to Grady Memorial Emergency Care Center who received intravenous fibrinolytics (tenecteplase or alteplase) for AIS treatment between January 2021 to April 2025. Patients under the age of 18, received intravenous fibrinolytics en route to Grady Memorial Hospital via our Mobile Stroke Unit, and in-house stroke patients were excluded from this study. Data was obtained from Institutional Stroke Committeefibrinolytic pharmacy data reports and the Marcus Stroke and Neuroscience Center. The primary outcome of the study was the functional status, defined as mRS, at discharge. Secondary outcomes included average 90-day mRS score, functional independence at 90 days (mRS score of 0-2), Onset-to-Treatment Time (OTT), DNT, DPT for thrombectomy patients, incidence of thrombectomy, successful reperfusion, defined as a TICI score of 2b or 3, incidence of symptomatic intracranial hemorrhage (sICH), defined as neurological deterioration (≥4-point NIHSS increase) attributed to new intracranial hemorrhage on imaging, and overall length of stay (LOS). 
Results:  
A total of 625 patients were included in the analysis; 246 received tenecteplase and 379 received alteplase. Median admission mRS scores were 0 (IQR 0–1) in both groups. Median admission NIHSS scores and functional independence at discharge did not differ between the tenecteplase and alteplase groups. Discharge mRSscores, and hospital length of stay were similar between the two groups. Median OTT time and DTN times were also not found to be significantly different. Inmechanical thrombectomy patients, median DTP time was 83 minutes for tenecteplase and 90.5 minutes for alteplase (p = 0.381). Mechanical thrombectomy was performed in 24.4% of patients treated with tenecteplase and 21.1% of patients treated with alteplase (p = 0.336) with successful reperfusion was achieved in 100% of tenecteplase and 98.8% of alteplase patients (p = 0.728). SICH occurred in 0.4% of patients in the tenecteplase group and 1.3% of patients in the alteplase group (p = 0.41). 
Conclusion:  
Tenecteplase and alteplase are considered similar when it comes to safety and efficacy of the two fibrinolytics with no significant difference to show between the two medications. Similar safety and efficacy features can show that tenecteplase could become a strong medication as reflected in our 2026 acute ischemic stroke guidelines. 
 
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Background/Purpose: Statins are essential in preventing stroke recurrence by atherosclerotic plaque accumulation, which can trigger acute ischemic strokes (AIS) when disrupted. Based on the differences in the pharmacokinetic profiles of atorvastatin and rosuvastatin, it is unclear if one agent is more effective at reducing the rates of stroke recurrence in adult survivors of AIS. The purpose of this study is to evaluate the rates of stroke recurrence in AIS patients receiving high-intensity statin therapy (HIST) with rosuvastatin or atorvastatin.  

Methods: In this retrospective cohort study adult patients with a diagnosis of AIS and discharged with HIST were screened if admitted from July 1, 2016, to October 31, 2020. High-intensity statin use was determined by having atorvastatin 40-80 milligrams daily or rosuvastatin 20-40 milligrams daily on the patient’s discharge medication list. The primary outcome of this study was rates of stroke recurrence within five years. Secondary outcomes evaluated were stroke recurrence within twenty-one days, stroke recurrence within one year, and rates of statin discontinuation within five years. 

Results: 5-year stroke recurrence from the initial AIS found that 10 (12.5%) of the atorvastatin and 6 (15%) of the rosuvastatin patients had an episode of stroke recurrence (OR 1.235; 95% CI, 0.415-3.681; p = 0.778). Similar to the primary outcomes, none of the secondary outcomes were statistically significant. 

Conclusions: Our results support either statin would be efficacious for secondary prevention, though there is an increased risk of myopathy associated with lipophilic statins (i.e., atorvastatin). Due to our studies' small sample size, it would be advantageous for future research to utilize a larger sample size to determine a potential clinical difference.