What is the initial management for patients with large vessel occlusions and Intracranial Atherosclerotic Disease (ICAD) presenting with a National Institutes of Health Stroke Scale (NIHSS) score of more than 5, specifically regarding the use of Tirofiban (Aggrastat)?

Tirofiban Use in Large Vessel Occlusions with ICAD and NIHSS >5

Intravenous tirofiban should be administered as an adjunctive therapy during mechanical thrombectomy for patients with large vessel occlusions and underlying intracranial atherosclerotic disease (ICAD), particularly when NIHSS is >5, as this approach was used successfully in 40-54% of patients in recent landmark trials demonstrating superior outcomes. 1

Evidence-Based Treatment Algorithm

Primary Intervention: Mechanical Thrombectomy

• Proceed immediately with mechanical thrombectomy for patients presenting with NIHSS >5 and confirmed large vessel occlusion, regardless of whether ICAD is suspected initially 1
• Treatment should be initiated (groin puncture) within 6 hours of symptom onset, though benefits extend to 24 hours in selected patients 1
• Target TICI 2b-3 reperfusion as rapidly as possible, as every 30-minute delay decreases good functional outcome probability by 8-14% 2, 3

Tirofiban Administration Protocol

When to administer tirofiban during the procedure: 1

• Immediately upon identifying underlying ICAD during thrombectomy when initial mechanical recanalization reveals fixed stenosis or when re-occlusion occurs after initial successful thrombectomy
• As first-line rescue therapy if standard thrombectomy techniques (aspiration, stent retriever) fail to achieve adequate reperfusion due to underlying atherosclerotic stenosis 4

The rationale is compelling: In the ATTENTION trial, 40% of patients received intravenous tirofiban during thrombectomy, while in the BAOCHE trial, 54% received tirofiban, both achieving favorable outcomes (mRS 0-3) in 46% of patients with low hemorrhagic complication rates (5-6% symptomatic ICH) 1

Technical Approach for ICAD-Related LVO

1. Begin with standard mechanical thrombectomy using aspiration alone (35% in ATTENTION), stent retriever alone (5%), or combined techniques (50%) 1

2. If underlying ICAD is identified:

   • Administer intravenous tirofiban as glycoprotein IIb/IIIa inhibitor 1, 4
   • Consider intracranial angioplasty (performed in 40-55% of cases in major trials) 1
   • Reserve stent placement for refractory cases (performed in 26-40% of cases) 1

3. Hemorrhagic rates remained acceptably low (6% symptomatic ICH in BAOCHE, 5% in ATTENTION) even with aggressive antiplatelet therapy and angioplasty/stenting 1

Critical Considerations for NIHSS >5

Why NIHSS >5 Matters

• The BAOCHE trial specifically enrolled patients with NIHSS ≥6, demonstrating 46% favorable outcomes versus 24% with medical therapy alone (ARR 1.81,95% CI 1.26-2.60, P<0.001) 1
• Patients with NIHSS >5 have sufficient neurological deficit to justify aggressive intervention, as the risk-benefit ratio strongly favors thrombectomy with adjunctive therapies 1

ICAD-Specific Challenges

• ICAD represents a therapeutic challenge requiring pharmacological and/or mechanical rescue treatment beyond standard thrombectomy 4
• The high rates of intracranial angioplasty (40-55%) and tirofiban use (40-54%) in successful trials reflect the frequency of ICAD in posterior circulation and in Asian populations 1
• Glycoprotein IIb/IIIa inhibitors like tirofiban are suggested as the best initial approach if reperfusion can be achieved after thrombectomy, with angioplasty/stenting reserved for refractory cases 4

Safety Profile and Monitoring

Hemorrhagic Risk Management

• Symptomatic intracranial hemorrhage rates were non-significantly higher but remained low (6% vs 1% in BAOCHE, RR 5.18,95% CI 0.46-42.18) 1
• Maintain blood pressure ≤180/105 mmHg during and for 24 hours after the procedure 2
• Hemorrhagic rates remained low even with combined angioplasty, stenting, and tirofiban administration 1

Mortality Benefit

• 90-day mortality was non-significantly lower in thrombectomy groups (31% vs 42%, RR 0.75) 1
• Procedural complications occurred in only 11% of cases 1

Common Pitfalls to Avoid

Do not withhold tirofiban due to excessive fear of hemorrhage - the landmark trials demonstrate acceptable safety profiles even with aggressive antiplatelet therapy during acute intervention 1

Do not delay thrombectomy to determine if ICAD is present - proceed immediately with mechanical intervention and add tirofiban when ICAD is identified during the procedure 1

Do not use other glycoprotein IIb/IIIa antagonists like abciximab - these are potentially harmful and should not be performed in acute ischemic stroke 1

Do not perform angioplasty/stenting as first-line therapy - tirofiban should be the initial rescue approach, with mechanical intervention reserved for cases where pharmacological therapy fails 4