Tirofiban in the endovascular treatment of intracranial aneurysm

• Prophylactic administration of tirofiban prevents ischemic events in endovascular treatment of unruptured intracranial aneurysms
• Evaluation of an endovascular aneurysm model in pigs for chronic experiments
• Safety and efficacy of tirofiban versus traditionaldualantiplatelettherapy in endovasculartreatment of intracranialaneurysms: asystematicreview and meta-analysis
• Safety and efficacy of tirofiban in the endovascular treatment of intracranial aneurysms: a systematic evaluation and meta-analysis
• Propensity score-adjusted analysis on early tirofiban administration to prevent thromboembolic complications during stand-alone coil embolization of ruptured aneurysms
• Safety and efficacy of coated flow diverters in the treatment of cerebral aneurysms during single antiplatelet therapy: A multicenter study
• Risk Factors, Antithrombotic Management, and Long-Term Outcomes of Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms
• Initial Experience with a New Self-Expanding Open-Cell Stent System with Antithrombotic Hydrophilic Polymer Coating (pEGASUS Stent) in the Treatment of Wide-Necked Intracranial Aneurysms

Tirofiban is increasingly being used as an adjunct during intracranial aneurysm endovascular treatment, particularly in Intracranial Aneurysm Flow Diversion or Intracranial aneurysm stent-assisted coiling. Its role is to prevent thrombotic complications while balancing the risk of bleeding.

Glycoprotein IIb/IIIa Receptor Blockade: Tirofiban inhibits platelet aggregation by blocking the glycoprotein IIb/IIIa receptor on the surface of platelets.

Preventing Thrombosis: This action is crucial during endovascular procedures, where the placement of devices like stents or flow-diverters can trigger platelet activation and clot formation.

Stent-Assisted Coiling:

During the coiling of intracranial aneurysms, stents are used to maintain coil stability and reduce aneurysm recurrence. Tirofiban reduces the risk of stent thrombosis during the procedure. Flow-Diverting Devices:

Inserting flow diverters to redirect blood flow from the aneurysm sac can activate platelets. Tirofiban helps mitigate this risk. Rescue Therapy:

Tirofiban is often administered as a rescue therapy in cases of intraoperative thrombus formation or significant platelet aggregation during endovascular IA procedures.

Evidence from Studies (e.g., Xiao et al., 2025) Safety:

Intracranial Hemorrhage (ICH): The pooled risk for ICH was 2%, indicating a low but significant bleeding risk. Non-ICH Bleeding Events (NoICH-BE): No significant increase in bleeding complications (pooled risk ~0%). Intraoperative Rupture Aneurysm (IRA): Low risk of intraoperative rupture (~2% pooled risk). Efficacy:

Thrombosis Prevention: Tirofiban significantly reduces intraoperative thrombotic events, with a reported pooled risk of 3%. Ischemic Stroke (IS): The risk of perioperative ischemic stroke is low (~2%). Thrombolysis: High success rate (96%) when thrombolysis was required intraoperatively. Clinical Prognosis: Favorable outcomes were reported in 91% of patients (modified Rankin Scale 0–2). Raymond and Roy Occlusion Classification (RROC): Favorable results (RROC 1–2) in 93% of patients. Advantages of Tirofiban Rapid Onset:

The immediate antiplatelet effect is useful in managing acute thrombotic events during surgery. Short Half-Life:

Allows for quick reversal of effects if bleeding complications occur. Ease of Administration:

Administered intravenously during the procedure, with titration based on patient needs. Minimizing Dual Antiplatelet Therapy:

In some cases, tirofiban may reduce the need for prolonged dual antiplatelet therapy (DAPT) postoperatively. Risks and Considerations Bleeding Complications:

Risk of intracranial hemorrhage, especially in cases with preexisting risk factors or procedural complications. Thrombocytopenia:

Rare but significant, requiring close monitoring of platelet counts. Off-Label Use:

Tirofiban is not universally approved for this indication, and its use often depends on institutional protocols and surgeon experience. Current Recommendations Patient Selection:

Tirofiban is most appropriate for patients at high risk of thrombotic complications undergoing stent-assisted coiling or flow diversion. Monitoring:

Continuous monitoring of platelet function and bleeding parameters is critical during and after administration. Combination Therapy:

Often used alongside or as a bridge to oral antiplatelet agents such as aspirin and clopidogrel. Dosing and Protocols:

Optimized dosing strategies tailored to procedural and patient-specific risks are crucial for minimizing complications. Conclusion Tirofiban is a promising agent for reducing thrombotic complications in the endovascular treatment of intracranial aneurysms. While it is generally safe and effective, its use requires careful patient selection, precise dosing, and vigilant monitoring to balance the benefits against the risks of bleeding. Further studies are needed to standardize protocols and provide long-term safety data.

Xiao et al. conducted a systematic review and meta-analysis to evaluate the efficacy and safety of tirofiban during intracranial aneurysm endovascular treatment. Relevant studies published before November 2024 were searched in PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases. Intracranial hemorrhage (ICH), thrombosis, and thrombolysis were the primary outcomes. Secondary outcomes included any non-ICH bleeding events (NoICH-BE), ischemic stroke (IS), intraoperative rupture aneurysm(IRA), follow-up prognosis, and Raymond and Roy classification (RROC). Meta-analysis was performed using Revman 5.3 and StataMP 64 to assess efficacy (thrombosis, IS, thrombolysis) and safety (ICH, NoICH-BE, IRA). A total of 33 studies involving 3,617 IA patients were included. The meta-analysis showed that after the use of tirofiban, the pooled risk (PR) for ICH was 2% ([95% CI, 1-3%]; P < 0.001), for NoICH-BE was 0% ([95% CI, 0-2%]; P > 0.05), for IRA was 2% ([95% CI, 1-3%]; P < 0.001), for thrombosis was 3% ([95% CI, 2-4%]; P < 0.001), for IS was 2% ([95% CI, 0-3%]; P < 0.001), for thrombolysis was 96% ([95% CI, 91-99%]; P < 0.001), for good prognosis (mRS 0-2) was 91% ([95% CI, 85-95%]; P < 0.001), and for RROC 1-2 was 93% ([95% CI, 90-96%]; P < 0.001). This systematic review and meta-analysis demonstrate that the use of tirofiban during endovascular treatment of IA is both feasible and safe ¹⁾.

Xiao et al. (2025) present a well-conducted systematic review and meta-analysis highlighting the safety and efficacy of tirofiban in the endovascular treatment of intracranial aneurysms. The findings are valuable for guiding clinical decision-making and expanding the evidence base for tirofiban use. However, limitations such as potential heterogeneity, lack of risk-of-bias assessment, and absence of subgroup and long-term analyses temper the study's conclusions. Future research should address these gaps to provide a more comprehensive understanding of tirofiban's role in this context.

aimed to evaluate the safety and efficacy of intravenous tirofiban administration versus dual antiplatelet therapy (DAPT) for stent-assisted coiling of RIAs within 24 hours after procedure.

Methods: From January 2015 to March 2019, two groups of patients with RIAs treated with stent-coiling were compared: the DAPT group (a loading dose of 300 mg clopidogrel and 300 mg aspirin) and the tirofiban group (intravenous administration of tirofiban 5 µg/kg over 1 min, followed by a maintenance dose of 0.1 µg/kg/min). The main outcome measures were rates of ischemic events and intracranial hemorrhage. Propensity score-matching (PSM) analysis was performed to correct imbalances in patient characteristics between the two groups.

Results: A total of 200 patients with RIAs were identified, with 36 patients in DAPT group and 164 in tirofiban group. After PSM, 36 patients in DAPT group and 72 patients in tirofiban group were matched. Ischemic events were noted for 8.33% (3/36) of patients in DAPT group, and 4.17% (3/72) in tirofiban group within 24 h after procedure(P = 0.398). Intracranial hemorrhage was noted for 0.00% (0/36) of patients in DAPT group, and 1.39% (1/72) in tirofiban group (P = 1.000) within 24 h. And no significant difference in the rate of ischemic or hemorrhagic events after 24 h was detected.

Intravenous administration of a low dose of tirofiban may represent a safe and effective alternative to DAPT during stent-assisted coiling of RIAs ²⁾.

conducted a retrospective review of a database containing a consecutive series of patients who underwent stent-assisted coiling for acutely ruptured intracranial aneurysms between March 2010 and January 2015. Intravenous tirofiban was administered to all patients before stent-assisted coiling, instead of premedication with loading doses of aspirin or clopidogrel.

Results: Forty patients with 41 aneurysms received intravenous tirofiban and underwent stent-assisted coiling. None of the patients had a newly developed intracerebral hemorrhage, subarachnoid hemorrhage, or intraventricular hemorrhage. The intraprocedural aneurysmal rupture occurred in 2 patients (5%). Cerebral infarction developed in 2 patients (5%). Ventriculostomy-related hemorrhage was seen in 2 of 10 patients in whom ventriculostomy was performed before or after coiling. Thirty-four (85%) patients had a good outcome (Glasgow Outcome Score of 4 or 5) at the time of discharge, but 1 patient died of cardiac arrest. None of the patients developed thrombocytopenia, retroperitoneal, gastrointestinal, or genitourinary bleeding related to tirofiban administration.

Tirofiban showed a low risk of symptomatic hemorrhagic or thromboembolic complications. Tirofiban may offer a safe and effective alternative as an antiplatelet premedication during stent-assisted coiling of acutely ruptured intracranial aneurysms ³⁾.

Between December 2008 and January 2015, Yoon et al. retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at the Pusan National University Yangsan Hospital, Yangsan, Korea. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra-arterial infusion of tirofiban via a microcatheter was also performed in 26 patients.

Thromboembolic formation during the procedure was detected in 25 cases. Intra-arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow-up period. Two cases of other complications occurred: hematuria and perioral bleeding.

Intravenous tirofiban, as a monotherapy or in addition to intra-arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion ⁴⁾.