Tirofiban for the Prevention of Early Neurological Deterioration After Intravenous Thrombolysis in Acute Ischemic Stroke

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA), administered within 4.5 hours of symptom onset, remains the standard treatment strategy for acute ischemic stroke. However, approximately 6-40% of patients experienced early neurological deterioration following intravenous thrombolysis, among which more than 70% resulted from ischemic events, with 20-34% due to early re-occlusion of the recanalized artery. Augmented platelet activation, triggered by the activated coagulation cascade and endothelial injury during rt-PA administration, is recognized as one of the primary reasons for ischemic events after intravenous thrombolysis. Early antiplatelet therapy following rt-PA effectively reduces neurological deterioration and improves functional outcomes. However, the current guidelines recommend that antiplatelet therapy should be initiated 24 hours after intravenous thrombolysis due to the potential risk of intracerebral hemorrhage.

Tirofiban, a glycoprotein (GP) IIb/IIIa receptor inhibitor renowned for its rapid action, high selectivity, and short half-life, has been found to exert a remarkable antiplatelet effect by effectively blocking the terminal pathway that triggers platelet aggregation. One recent randomized trial found that among patients with acute non-cardioembolic ischemic stroke who presented within 24 hours of symptom onset, intravenous tirofiban resulted in a lower likelihood of early neurological deterioration than oral aspirin, without increasing the risk of intracranial hemorrhage or systematic bleeding. Another randomized trial found that treatment with intravenous tirofiban administration was safe and significantly improved 3-month functional outcomes in patients who experienced early neurological deterioration or no improvement within 24 hours of intravenous thrombolysis, compared with aspirin. Furthermore, our previous study found that early administration of tirofiban in patients with early neurological deterioration within the first 24 hours of intravenous thrombolysis did not increase the risk of symptomatic intracerebral hemorrhage, any intracerebral hemorrhage, or mortality. In contrast, it was associated with neurological improvement at 3 months. However, whether early administration of tirofiban can safely and effectively prevent neurological deterioration in patients with acute ischemic stroke treated with intravenous thrombolysis within 24 hours remains unclear, while the subset of patients who may benefit from early antiplatelet therapy.

Inclusion criteria

• Age ≥18 years old;
• Acute ischemic stroke treated with intravenous thrombolysis with alteplase or tenecteplase within 4.5 hours of onset or time last known well and can receive the study drug treatment within 3 hours of initiating intravenous thrombolysis.
• Residual NIHSS score ≥ 5 points at randomization (at least 1 hour after intravenous thrombolytic therapy).
• Post-thrombolysis imaging shows that the offending artery is consistent with moderate or severe intracranial atherosclerotic stenosis (within 50%~99%)
• Informed consent obtained from patients or their acceptable surrogates.

Exclusion criteria

• Intracranial hemorrhage confirmed by imaging post-thrombolysis.
• Stroke caused by other determined causes, including moyamoya disease, artery dissection, arteritis, etc.
• Scheduled for or received endovascular treatment after onset.
• Definite or suspected cardioembolic stroke.
• Definite anticipation of developing indications for anticoagulant therapy during the study period (e.g., atrial fibrillation, mechanical heart valve, deep vein thrombosis, pulmonary embolism, antiphospholipid syndrome, hypercoagulable state).
• Use of antiplatelet or anticoagulant therapy within one week pre-stroke.
• Pre-stroke mRS score ≥ 2.
• Severe consciousness disturbance with NIHSS item 1a (level of consciousness) >1 point at randomization.
• History of tirofiban allergy or its solvents.
• History of platelet count < 100 × 109/L caused by tirofiban.
• Major surgical operation within 6 weeks.
• Major systemic hemorrhage within 30 days;
• Determined coagulation disorders, platelet dysfunction, or platelet count < 100*109/L.
• Currently pregnant or lactating;
• Uncontrolled hypertension with systolic blood pressure > 180 mmHg or diastolic blood pressure > 110 mmHg.
• Acute pericarditis or hemorrhagic retinopathy.
• Presence of malignant tumors, chronic hemodialysis, severe renal insufficiency (GFR < 30 ml/min or serum Cr > 220 μmol/L (2.5 mg/dl)), severe hepatic insufficiency (serum ALT > 2 times the upper limit of normal, or serum AST > 2 times the upper limit of normal), severe heart failure (NYHA class III or IV).
• Severe non-cardiovascular complications with an expected survival of less than 6 months.
• Unavailability for follow-up.
• Presence of dementia, psychiatric disorders, or other known neurological conditions that complicate follow-up.
• Participated in this study in the past.
• Current participation in another therapeutic study with ongoing treatment and follow-up.
• Other conditions that are not suitable for participation in this study as determined by the investigator.