http://www.springerlink.com/content/u315778702g1jj86/

Jee-Hyun Kwon, Shang Hun Shin, Young Cheol Weon, Jae Cheol Hwang and Seung Kug Baik. Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. NeuroradiologyVolume 53, Number 10, 779-785, DOI: 10.1007/s00234-011-0939-y

Intra-arterial chemical thrombolytic therapy of acute stroke is rapidly gaining strides. However, the drugs and their dosage to be used is far from clear, with ever neurointerventionist using a different protocol. Even then, few points are becoming lucid;

1. Fibrin busting drugs e.g tPA or urokinase is not effective in a substantial number of patients

2. Antiplatelets are vey handy in intra-arterial thrombolysis

3. Intra-arterial heparin also can be handy in many instances

Reports of  groups using antiplatelets have been published.

A recent one studied 16 patients with failed thrombolysis after IA urokinase, in whom tirofiban was used. They achieved good recanalisation rates. However, 6 patients had ICH, which to my mind does not really augur well for this idea, even though the authors themselves say that it is a good result.

Probably we need to design a chemical IA thrombolysis dosage using both Urokinase/tPA and antiplatelets rather than using one after the other has failed.

Abstract

Introduction 

Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke.

Methods 

We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36–85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0–2).

Results 

Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH.

Conclusion 

Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.

Keywords  Acute ischemic stroke – Intra-arterial – Tirofiban – Thrombolysis