Intra-arterial tirofiban infusion for partial recanalization with stagnant flow in hyperacute cerebral ischemic stroke

Abstract

Early reocclusion is a major concern associated with poor clinical outcomes in patients with an ischemic cerebral stroke. This occurs most frequently in patients with partial initial recanalization. This study focuses on partial recanalization with stagnant antegrade flow after intravenous (IV) tPA or spontaneously, treated with the administration of intra-arterial (IA) tirofiban. Three patients with initial M1 occlusion on diagnostic studies had an occluded segment that was recanalized with stagnant flow after IV tPA or spontaneously. In all cases, IA tirofiban was administrated. We evaluated the distal blood flow and the degree of vascular narrowing in the pre and post-procedure angiography and at follow-up in addition to the clinical status. In all patients, severe vascular narrowing with stagnation of blood flow was detected in the initial M1. After infusion of IA tirofiban, improvement of the distal blood flow was achieved rapidly within 40 minutes in all patients. The severe vascular narrowing resolved rapidly in two patients without residual stenosis. In one patient, moderate vascular narrowing was still present. The median baseline National Institutes of Health Stroke Scale (NIHSS) scores were 18 and the median post-procedural NIHSS scores were 2 at two weeks. No intracerebral hemorrhage occurred in any of the patients. Treatment with IA tirofiban was safe and effective in patients with partial initial recanalization. It can be suggested that detection of any partial recanalization is time for administration of glycoprotein IIb-IIIa receptor inhibitor in hyperacute ischemic stroke.

Figure 1

Case 3. Middle cerebral artery occlusion treated with intra-arterial tirofiban only. A) Initial CTA shows occlusion of the left M1 segment. B) CTA source image reveals a subtle low density in the left basal ganglia and left frontal lobe. C) Initial catheter angiography reveals partial recanalization with a focal M1 narrowing and antegrade stagnant flow without any medication. D) After infusion of 0.25 mg of tirofiban, improvement of the distal blood flow was noted. E) After infusion of 0.5 mg of tirofiban, mild resolution of focal stenosis and the new appearance of another lenticulostriate artery were noted. F) After infusion of 0.75 mg of tirofiban, complete resolution of focal stenosis, and new appearance of another lenticulostriate artery as well as another MCA division with occlusion of the M2 distal segment was noted. G) After infusion of 1 mg of tirofiban, no missing arteries were noted and blood flow through the M2 segment was completely restored. H) The post-procedural diffusion weighted image reveals high signal intensity in the left basal ganglia and left frontal lobe. No intracerebral hemorrhage or new infarction occurred.

Figure 1

Case 3. Middle cerebral artery occlusion treated with intra-arterial tirofiban only. A) Initial CTA shows occlusion of the left M1 segment. B) CTA source image reveals a subtle low density in the left basal ganglia and left frontal lobe. C) Initial catheter angiography reveals partial recanalization with a focal M1 narrowing and antegrade stagnant flow without any medication. D) After infusion of 0.25 mg of tirofiban, improvement of the distal blood flow was noted. E) After infusion of 0.5 mg of tirofiban, mild resolution of focal stenosis and the new appearance of another lenticulostriate artery were noted. F) After infusion of 0.75 mg of tirofiban, complete resolution of focal stenosis, and new appearance of another lenticulostriate artery as well as another MCA division with occlusion of the M2 distal segment was noted. G) After infusion of 1 mg of tirofiban, no missing arteries were noted and blood flow through the M2 segment was completely restored. H) The post-procedural diffusion weighted image reveals high signal intensity in the left basal ganglia and left frontal lobe. No intracerebral hemorrhage or new infarction occurred.

Figure 2

Case 2. Middle cerebral artery occlusion treated with IV tPA and IA tirofiban. A) Initial MRA shows occlusion of the right M1 segment. B) Diffusion-weighted image reveals a subtle high signal intensity in the right basal ganglia and right occipital lobe. C) Initial catheter angiography reveals partial recanalization with a focal filling defect in the M1. D) Oblique angiography shows focal narrowing of the M1 mid-portion. E) After infusion of 0.5 mg of tirofiban, near complete resolution of the focal filling defect and focal vascular narrowing in the right M1 was noted. F) Post-procedural diffusion-weighted image reveals no interval change, compared to the initial diffusion-weighted image.

Figure 3

Case 1. Middle cerebral artery occlusion treated with IV tPA and IA tirofiban. A) Initial CTA shows occlusion of the left M1 segment. B) CTA source image reveals a subtle low density in the left basal ganglia and insular cortex area. C) Initial catheter angiography reveals partial recanalization with a focal M1 narrowing and antegrade stagnant flow after IV tPA. D) After infusion of 1.5 mg of tirofiban, improvement of the distal blood flow was noted. However, moderate vascular narrowing remained. E) Moderate vascular narrowing improved to mild stenosis on follow up MRA 10 months later.

Figure 3

Case 1. Middle cerebral artery occlusion treated with IV tPA and IA tirofiban. A) Initial CTA shows occlusion of the left M1 segment. B) CTA source image reveals a subtle low density in the left basal ganglia and insular cortex area. C) Initial catheter angiography reveals partial recanalization with a focal M1 narrowing and antegrade stagnant flow after IV tPA. D) After infusion of 1.5 mg of tirofiban, improvement of the distal blood flow was noted. However, moderate vascular narrowing remained. E) Moderate vascular narrowing improved to mild stenosis on follow up MRA 10 months later.