Tirofiban use in acute ischemic stroke: a case series and review of literature
Chun-Min Wang, MD 1 , Yu-Ming Chang, MD 1 ,
1 National Cheng Kung University Hospital
Pi-Shan Sung , MD
National Cheng Kung University Hospital
We retrospectively reviewed patient administered with Tirofiban in a tertiary medical center during 2017 to 2020. The basic characteristics, stroke severity, indication, dosage of Tirofiban, symptomatic intracranial hemorrhage, functional outcome at discharge and 3 months were reviewed. A total of 13 patients was enrolled into this study. The mean age was 61.6 (Range: 36-84), and 10 of them is male. The median NIHSS was 12 (Range: 5-36). Seven patients received Tirofiban due to recurrent occlusion or residual stenosis during thrombectomy, with 2 of 7 receiving only small amount (5mg) of intraarterial injection (IA); 5 of 7 receiving IA following intravenous infusion (a total of 12.5 mg). Five patients received IV Tirofiban infusion due to critical stenosis of large vessel (basilar artery: 3, middle cerebral artery: 2), with total dose of 12.5 or 25mg. The good outcome (greatly improved NIHSS and/or good functional outcome) showed in 70% (5/7) in thrombectomy group, and 40% (2/5) in critical stenosis group. There were 2 patients with symptomatic ICH , one with BA occlusion underwent IA thrombectomy following low dose of IA injection of Tirofiban, another with left posterior cerebral artery and vertebral artery critical stenosis.
Tirofiban is an antiplatelet agent, which belongs to the class of glycoprotein (GP) IIb/IIIa inhibitors. It is mainly administered as adjunctive therapy for acute coronary syndromes and percutaneous coronary intervention. The safety of Tirofiban use in acute ischemic stroke had been validated in SaTIS trial, but the results failed to prove a clinical benefit, probably because of delayed initiation. However, several studies found it may benefit patient in certain situations, including in those with neurological deterioration after intravenous thrombolytic treatment, and residual arterial stenosis after intraarterial thrombectomy. There were no consensus in the adequate indication or timing of Tirofiban use. In our study, we found that there are two potential situations using Tirofiban may be considered. One is patients with residual stenosis or recurrent occlusion of large vessel during intraarterial thrombectomy by intra-arterial injection following intravenous infusion of Tirofiban. Another is patients with critical stenosis during acute stage, but not a candidate of IV thrombolytic treatment or IA thrombectomy. In our case series, there were the two patients with SICH, and one of them was probably due to procedural complication. Further randomized trial may target the patients with the two situations mentioned above to prove the efficacy of Tirofiban use in acute ischemic stroke.