Use of tirofiban in distal basilar artery occlusion in acute ischemic stroke: a case report

Abstract

Case Presentation: A 71-year-old male patient with a history of arterial hypertension and diabetes mellitus, admitted under the care of Vascular Surgery due to a right lower limb transfemoral amputation. Sixteen days after admission, the patient developed left-sided hemiparesis and dysarthria, with an NIHSS score of 9. The initial neurological evaluation occurred approximately 10 hours after the ictus. Non-contrast head CT showed no extensive ischemic changes in the posterior circulation, with a PC-ASPECTS of 10. Computed Tomography Angiography (CTA) revealed multifocal atherosclerosis in both anterior and posterior circulations, as well as occlusion of the distal third of the basilar artery, with collateral circulation through the communicating arteries and filling of the basilar tip. The patient was outside the window for intravenous thrombolysis. Mechanical thrombectomy was not performed due to a reduction in the NIHSS score to 4, with maintenance of clinical and neurological stability in the context of an extended window. Intravenous infusion of tirofiban for 48 hours was the chosen management. A follow-up CTA, performed on the 3rd day after the initial evaluation, showed recanalization of the basilar artery. The patient remained clinically stable during hospitalization and, at a one-month outpatient follow-up, presented an NIHSS score of 4. Discussion: Tirofiban is a selective glycoprotein IIb/IIIa receptor inhibitor antiplatelet agent, with a rapid onset of action and a short half-life. Platelet aggregation inhibition is reversible after discontinuation of the infusion. In acute ischemic stroke, its role remains controversial and outside the routine recommendations of major guidelines, especially outside the context of endovascular therapy. Recent randomized trials suggest a reduction in early neurological deterioration in selected patients with non-cardioembolic ischemic stroke, while meta-analyses indicate potential functional benefit in populations without reperfusion therapies, without a consistent increase in symptomatic intracranial hemorrhage or mortality. The above case supports the need for individualized decision-making, particularly when other reperfusion therapies are not indicated. Final Comments: The use of Tirofiban in the treatment of acute ischemic stroke is not yet a formal recommendation from the major national and international societies. However, current studies show that its use may be considered in specific situations, such as in cases ineligible for thrombolysis or mechanical thrombectomy. Available clinical trials and meta-analyses show better functional outcomes (mRS 0–1 at 90 days) with the use of Tirofiban compared to Acetylsalicylic Acid alone, without a consistent increase in symptomatic intracranial hemorrhage The medical literature still lacks further studies to better establish the risks, benefits, and indications for Tirofiban use in the context of ischemic stroke.