Efficacy of Simultaneous Infusion of Tirofiban with Intravenous Thrombolysis in Patients with Acute Anterior Choroidal or Paramedian Pontine Infarction: TITACIPPI Study

Background and Purpose

Intravenous thrombolysis combined with tirofiban (IVT plus tirofiban) has been reported to be more effective than IVT alone in preventing early neurological deterioration (END) and improving 3-month functional outcomes in patients with ischemic stroke. This study aimed to assess the radiological efficacy and safety of simultaneous (or within 60 minutes) IVT plus tirofiban versus IVT alone specifically in patients with anterior choroidal infarction (ACI) or paramedian pontine infarction (PPI), two subtypes with a high risk of END.

Methods

We conducted a single-center, retrospective study including consecutive patients aged ≥18 years treated during two distinct periods: one with standard IVT alone and one with IVT plus tirofiban. The primary endpoint was ≥20% reduction in lesion volume on 24-hour diffusion-weighted imaging (DWI). Secondary endpoints included early clinical improvement at 24 hours and 7 days (or discharge), functional independence (modified Rankin Scale (mRS) scores ≤2 and ≤1) at 3 months, and END. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and major systemic bleeding (MSB). A subgroup analysis compared clinical outcomes in patients with « lesion reversal » versus patients with no « lesion reversal ».

Results

A total of 58 patients were analyzed (30 IVT plus tirofiban; 28 IVT alone). Lesion reversal ≥20% was more frequently observed in the IVT plus tirofiban group (adjusted odds ratio, 8.58; 95% CI, 2.09–35.28; p=0.001). No significant differences were found between groups for END or 3-month functional outcomes (mRS ≤2 or ≤1). One non-fatal MSB occurred in the IVT alone group. No cases of sICH were observed in either group. Overall lesion reversal was significantly associated with better early and late outcomes, and with IVT plus tirofiban treatment.

Discussion and Conclusions

This study suggests that IVT plus tirofiban improves radiological outcomes and may be a promising therapeutic option in patients with ACI/PPI, without increasing the risk of bleeding compared to IVT alone.

KEY MESSAGE

What is already known on this topic: Branch atheromatous disease related ischemic strokes (BADRIS) carry a substantial risk of long-term disability because early neurological deterioration (END) is frequent even after intravenous thrombolysis (IVT). However, the role of IVT in preventing END in patients with BADRIS is not well established.

What this study adds: This single-center retrospective study provides real-world evidence that IVT plus tirofiban is associated with a lesion reversal ≥20% on 24-hour diffusion-weighted imaging (DWI) compared to IVT alone. The study also provides evidence that lesion reversal is associated with better early and late outcomes, and with IVT plus tirofiban treatment.

How this study might affect research, practice or policy: These findings support the use of IVT plus tirofiban in patients with BADRIS. This combination promotes lesion reversal, thereby improving functional outcomes and reducing the risk of END. Larger prospective multicenter randomized trials are needed to confirm these findings and to determine whether this strategy provides a functional benefit at 3 months.