The Safety and Efficiency of Tirofiban in Acute Ischemic Stroke Patients Treated with Mechanical Thrombectomy: A Multicenter Retrospective Cohort Study

Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis

BACKGROUND

Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT).

METHODS

Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation.

RESULTS

Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26).

CONCLUSION

For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.

Antiplatelet Therapy in Neurointervention

The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.

Meta-analysis of the efficacy and safety of tirofiban in patients with acute ischaemic stroke undergoing mechanical thrombectomy

INTRODUCTION

Mechanical thrombectomy is now widely used in acute ischaemic stroke, but its adjunctive antiplatelet aggregation regimen is controversial. This study aimed to investigate the safety and efficacy of tirofiban in patients with acute ischaemic stroke (AIS) who underwent mechanical thrombectomy.

METHODS

We systematically searched Pubmed, Embase, Cochrane Library, and Web of science. Randomized controlled studies and cohort studies comparing the tirofiban group and non-tirofiban group (control group) in patients with AIS who underwent mechanical thrombectomy. The primary safety outcomes were symptomatic intracranial hemorrhage (sICH), 3-month mortality, and re-occlusion rate. The primary efficacy outcomes were good functional outcome (mRS 0-2), excellent functional outcome (mRS 0-1), and successful recanalization (mTICI≥2b).

RESULTS

We included 22 studies with a total of 6062 patients. For safety outcomes, the tirofiban group had a non-significantly higher rate of sICH (OR = 0.90, 95 % CI = 0.73-1.10, P = 0.29) and a significantly lower rate of re-occlusion (OR = 0.40, 95 % CI = 0.19-0.82, P = 0.01) and 3-month mortality (OR = 0.71, 95 % CI = 0.61-0.82, P < 0.00001) compared to the control group. In terms of efficacy outcomes, significant improvement in good functional outcomes (mRS 0-2) (OR = 1.24, 95 % CI = 1.11-1.39, P = 0.0002) and recanalization rate (OR = 1.38, 95% CI = 1.17-1.62, P = 0.0001) compared to tirofiban, but not significant improvement in excellent functional outcomes(OR = 1.14, 95 % CI = 0.93-1.39, P = 0.21). In addition, compared with cardiogenic stroke, the large atherosclerotic stroke had a higher rate of good functional outcome (OR = 1.58, 95 % CI = 1.18-2.11, P = 0.002) and a lower rate of 3-month mortality (OR = 0.58, 95 % CI = 0.39-0.85, P = 0.005). Subgroup analysis by route of administration showed a significant improvement in good functional outcome in the intravenous group (OR = 1.27, 95 % CI = 1.08-1.50, P = 0.004), while no significant difference was found between the arterial and arteriovenous groups.

CONCLUSION

Treatment with tirofiban in patients with AIS with mechanical thrombectomy is effective in improving functional prognosis, arterial recanalization rates, and reducing 3-month mortality and re-occlusion rates, particularly in patients with large atherosclerotic stroke, without increasing the rate of symptomatic intracranial hemorrhage. Intravenous administration of tirofiban significantly improves the clinical prognosis compared to arterial administration. Tirofiban is effective and safe in patients with AIS.

C1QC, VSIG4, and CFD as Potential Peripheral Blood Biomarkers in Atrial Fibrillation-Related Cardioembolic Stroke

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. We aimed to identify novel potential biomarkers with diagnostic value in patients with atrial fibrillation-related cardioembolic stroke (AF-CE).Publicly available gene expression profiles related to AF, cardioembolic stroke (CE), and large artery atherosclerosis (LAA) were downloaded from the Gene Expression Omnibus (GEO). Differentially expressed genes (DEGs) were identified and then functionally annotated. The support vector machine recursive feature elimination (SVM-RFE) and least absolute shrinkage and selection operator (LASSO) regression analysis were conducted to identify potential diagnostic AF-CE biomarkers. Furthermore, the results were validated by using external data sets, and discriminability was measured by the area under the ROC curve (AUC). In order to verify the predictive results, the blood samples of 13 healthy controls, 20 patients with CE, and 20 patients with LAA stroke were acquired for RT-qPCR, and the correlation between biomarkers and clinical features was further explored. Lastly, a nomogram and the companion website were developed to predict the CE-risk rate. Three feature genes (C1QC, VSIG4, and CFD) were selected and validated in the training and the external datasets. The qRT-PCR evaluation showed that the levels of blood biomarkers (C1QC, VSIG4, and CFD) in patients with AF-CE can be used to differentiate patients with AF-CE from normal controls (P < 0.05) and can effectively discriminate AF-CE from LAA stroke (P < 0.05). Immune cell infiltration analysis revealed that three feature genes were correlated with immune system such as neutrophils. Clinical impact curve, calibration curves, ROC, and DCAs of the nomogram indicate that the nomogram had good performance. Our findings showed that C1QC, VSIG4, and CFD can potentially serve as diagnostic blood biomarkers of AF-CE; novel nomogram and the companion website can help clinicians to identify high-risk individuals, thus helping to guide treatment decisions for stroke patients.

Tirofiban for Acute Ischemic Stroke Patients Receiving Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

INTRODUCTION

Tirofiban has been used as a rescue when thrombectomy is not successful in endovascular therapy (EVT) for acute ischemic stroke (AIS), but the use of tirofiban after intravenous thrombolysis (IVT) is controversial. The purpose of this meta-analysis was to evaluate the safety and efficacy of tirofiban combined with IVT in AIS compared with not receiving tirofiban.

METHODS

The PubMed and Embase databases were searched for all relevant studies published up to August 31, 2021. The safety endpoints included symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), and mortality. The efficacy endpoint was the modified Rankin Scale (mRS) score at the 3-month follow-up.

RESULTS

Seven articles (1,036 patients) were included. Of these, 444 patients received tirofiban, and 592 patients did not. Meta-analysis showed that tirofiban did not increase the risk of sICH (OR 0.98; 95% CI 0.50-1.93; p = 0.96), any ICH (OR 0.94; 95% CI 0.63-1.39; p = 0.75) or mortality (OR 0.67; 95% CI 0.39-1.15; p = 0.15) and tended to be associated with a favorable functional outcome (OR 1.33; 95% CI 0.99-1.78; p = 0.06) in patients with AIS. Subgroup analysis showed that bridging therapy combined with tirofiban could reduce mortality (OR 0.47; 95% CI 0.23-0.98; p = 0.04). Tirofiban significantly improved the favorable functional outcome in patients with IVT only (non-EVT) (OR 1.98; 95% CI 1.30-3.02; p = 0.002).

CONCLUSION

Intravenous tirofiban could be safe for patients with AIS undergoing IVT, regardless of receiving EVT. Intravenous tirofiban may reduce mortality rates for patients undergoing bridging therapy. It also could increase the likelihood of a favorable functional outcome, especially for patients receiving IVT only.

Meta-Analysis of Predictive Role of Early Neurological Deterioration after Intravenous Thrombolysis

With the popularization of intravenous thrombolysis, more and more people use intravenous thrombolysis to treat related diseases, but problems also arise. There are still a considerable number of patients with early disease after thrombolytic therapy not only not significantly improving, but also progressing, that is, early neurological deterioration (END). In view of this problem, the prediction of END after intravenous thrombolysis becomes very important. With the development of medical technology, research on the prediction of END after intravenous thrombolysis has gradually been carried out. Effective prediction is of great significance for the prevention and treatment of END after intravenous thrombolysis. This article aimed to carry out a meta-analysis of the predictive role of END after intravenous thrombolysis. Through an informed analysis of all studies of this type in this field, this article determines a method for predicting END after intravenous thrombolysis. The actual effect of its role is revealed in this paper, and its purpose is to promote the development of this field. This article addresses the same type of study on the predictive role of neurological deterioration after intravenous thrombolysis. The article performs test and meta-analysis of its role by conditionally searching for literature studies. It is explained using the relevant theoretical formulas. The analysis results show that the prediction of END after intravenous thrombolysis in this paper can effectively help make a preliminary judgment on the possible later neurological deterioration. Although there is an error between the predicted curve and the actual curve, the difference between the two is between 1% and 5%. It can basically effectively predict the occurrence of END. Therefore, the prediction of END after intravenous thrombolysis has a very large preventive effect on the END after intravenous thrombolysis.

Hyperacute treatment of childhood stroke in Lyme neuroborreliosis: report of two cases and systematic review of the literature

The safety and efficacy of hyperacute reperfusion therapies in childhood stroke due to focal cerebral arteriopathy (FCA) with an infectious and inflammatory component is unknown. Lyme neuroborreliosis (LNB) is reported as a rare cause of childhood stroke. Intravenous thrombolysis (IVT) and endovascular therapy (EVT) have not been reported in LNB-associated stroke in children. We report two children with acute stroke associated with LNB who underwent hyperacute stroke treatment. A systematic review of the literature was performed to identify case reports of LNB-associated childhood stroke over the last 20 years. Patient 1 received IVT within 73 min after onset of acute hemiparesis and dysarthria; medulla oblongata infarctions were diagnosed on magnetic resonance imaging (MRI). Patient 2 received successful EVT 6.5 hr after onset of progressive tetraparesis, coma, and decerebrate posturing caused by basilar artery occlusion with bilateral pontomesencephalic infarctions. Both patients exhibited a lymphocytic cerebrospinal fluid (CSF) pleocytosis and elevated antibody index (AI) to Borrelia burgdorferi. Antibiotic treatment, steroids, and platelet inhibitors including tirofiban infusion in patient 2 were administered. No side effects were observed. On follow-up, patient 1 showed good recovery and patient 2 was asymptomatic. In the literature, 12 cases of LNB-associated childhood stroke were reported. LNB-associated infectious and inflammatory FCA is not a medical contraindication for reperfusion therapies in acute childhood stroke. Steroids are discussed controversially in inflammatory FCA due to LNB. Intensified antiplatelet regimes may be considered; secondary prophylaxis with acetyl-salicylic acid (ASA) is recommended because of a high risk of early stroke recurrence.

Can Tirofiban Improve the Outcome of Patients With Acute Ischemic Stroke: A Propensity Score Matching Analysis

Objective: To evaluate the efficacy and safety of tirofiban for patients with acute ischemic stroke (AIS), especially posterior circulation stroke (PCS).

Methods: We enrolled consecutive patients with AIS who suffered large artery occlusion (LAO) and underwent mechanical thrombectomy (MT) between January 2016 and May 2020. Patients were divided into two groups according to whether tirofiban was used during MT. The primary efficacy outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0–2 at 3 months. The safety outcomes were the rate of mortality at 3 months and the presence of intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Cohorts were balanced using 1:1 propensity score matching (PSM). Subgroup analysis was further performed to compare the efficacy and safety of tirofiban between the anterior circulation stroke (ACS) and PCS groups.

Results: A total of 292 patients were eligible for this study and divided into the tirofiban group (n = 51) and the no-tirofiban group (n = 241). In the propensity-score-matched cohort, the tirofiban group had a higher rate of favorable outcomes than the no-tirofiban group (49.0 vs. 25.5%, p = 0.014), and the mortality at 3 months showed a greater downward trend in the tirofiban group than the no-tirofiban group (15.6 vs. 33.3% p = 0.064). The risk of sICH and ICH was the same between the tirofiban and control groups (17.6 vs. 27.4% p = 0.236, 31.3 vs. 45.1% p = 0.154, respectively). Tirofiban use was predictive of favorable outcomes [adjusted odds ratio (aOR) = 2.87, 95% confidence interval (CI) 1.52–6.44, p = 0.043] after multiple logistic regression analysis. Subgroup analysis revealed that tirofiban use was significantly associated with favorable outcomes in ACS (aOR = 3.66, 95% CI 1.24–5.22, p = 0.019) but not in PCS (aOR = 1.12, 95% CI 0.47–7.52, p = 0.570).

Conclusion: We demonstrated that tirofiban may be associated with improving favorable outcome for the AIS patients who underwent MT, without increasing ICH or sICH. Furthermore, our results indicated that for PCS patients tirofiban may not be associated with favorable outcome, and more comprehensive randomized controlled trials are needed to confirm this finding.

Antiplatelet therapy and outcomes following endovascular therapy for acute ischemic stroke: A systemic review and meta-analysis

OBJECTIVE

The outcomes of antiplatelet therapy (APT) in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT) remains controversial. Thus, we sought to make a systematic review and meta-analysis of recent clinical trials to confirm the safety and efficacy of APT.

METHODS

All of clinical trails were systematically retrieved from PubMed, Embase and Cochrane. The endpoints or main outcome measures included symptomatic intracranial hemorrhage (sICH), 3-month mortality, successful recanalisation (SR) and 3-month functional independence (FI). Odd ratios (ORs) with their 95% confidence intervals (CIs) were calculated to synthesize effect size by using random-effects models. Sensitivity analysis was performed via calculation of rest data owiting one by one.

RESULTS

23 articles were included after screening. APT as an adjunct to EVT was associated with a higher likelihood of pooled successful recanalisation (OR 1.46, 95% CI 1.07-2.00) and 3-month FI (OR 1.24, 95% CI 1.01-1.51), no associated with sICH and 3-month mortality. However, Sensitivity analysis indicated that the association between APT and SR and 3-month FI were unstable. For patients with prior use of APT or receiving intravenous thrombolysis before EVT, no associated were found between APT and all of endpoints above.

CONCLUSION

Although adjuvant APT appears to increase the number of SR and 3-month FI, the results were unstable. Randomised controlled trials are needed to confirm the efficacy.

Perfusion image guided mechanical thrombectomy combined with tirofiban successfully revascularize systemic lupus erythematosus related acute large vessel occlusion: A case report

RATIONALE

Systemic lupus erythematosus (SLE) is an important cause of stroke, more than a half the cases present as acute ischemic stroke. Thrombolysis is an effective choice in most cases, but for large vessel occlusion, mechanical thrombectomy is more effective. Here we reported a case of SLE-related stroke with left middle cerebral artery (MCA) occlusion, who was successfully treated by MT and tirofiban.

PATIENT CONCERN

A 38-year-old female suffered from right hemiplegia and aphasia for 8 hours. She was diagnosed with SLE 20 years ago, and neuropsychiatric SLE was considered 8 months before this onset. One month ago, glucocorticoids were discontinued by herself because of deterioration of bilateral femoral head osteonecrosis.

DIAGNOSIS

Left MCA occlusion was confirmed by computed tomography perfusion.

INTERVENTION

Immediate mechanical thrombectomy was performed and tirofiban was given to prevent re-occlusion of left MCA. Twenty fourhours later oral antiplatelet was given after intracranial hemorrhage was ruled out.

OUTCOMES

Her neurological symptom improved several days later, and she was transferred to further rehabilitation. At 4 months follow-up she can live independently with mild hypophrasia. There was no further events of ischemic stroke in 1-year follow-up.

LESSONS

Mechanical thrombectomy is a highly effective and indispensable treatment for SLE related large vessel occlusion. In addition, tirofiban may reduce vessel reocclusion in special cases such as SLE and artery stenosis.