Intravenous Tirofiban Versus Alteplase Before Endovascular Treatment in Acute Ischemic Stroke: A Pooled Analysis of the DEVT and RESCUE BT Trials.

Background: The present study aimed to evaluate the efficacy and safety of intravenous tirofiban versus alteplase before endovascular treatment (EVT) in acute ischemic stroke patients with intracranial large vessel occlusion.
Methods: This was a post hoc analysis using data from 2 multicenter, randomized trials: the DEVT trial (Direct Endovascular Treatment for Large Vessel Occlusion Stroke) from May 2018 to May 2020 and the RESCUE BT trial (Intravenous Tirofiban Before Endovascular Thrombectomy for Acute Ischemic Stroke) from October 2018 to October 2021. Patients with acute intracranial large vessel occlusion within 4.5 hours from last known well were dichotomized into 2 groups: tirofiban plus EVT versus alteplase bridging with EVT. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 3-month mortality. Multivariable logistic regression (adjusting for baseline systolic blood pressure, occlusion site, onset-to-puncture time, anesthesia, and first choice of EVT) and propensity score overlap weighting (balance in demographic covariates, stroke characteristics, and initial management between groups) were performed.
Results: One-hundred and eighteen alteplase-treated patients in the DEVT trial and 98 tirofiban-treated patients in the RESCUE BT trial were included (median age, 70 years; 115 [53.2%] men). The rate of functional independence was 60.2% in the tirofiban group compared with 46.6% in the alteplase group (adjusted odds ratio, 1.25 [95% CI, 0.60-2.63]). Compared with alteplase, tirofiban was not associated with increased risk of symptomatic intracranial hemorrhage (6.8% versus 9.2%; P =0.51) and mortality (17.8% versus 19.4%; P =0.76). The propensity score overlap weighting analyses showed consistent outcomes.
Conclusions: Among patients with intracranial large vessel occlusion within 4.5 hours of onset, tirofiban plus EVT was comparable to alteplase bridging with EVT regarding the efficacy and safety outcomes. These findings should be interpreted as preliminary and require confirmation in a randomized trial.
Registration: URL: https://www.chictr.org.cn; Unique identifiers: ChiCTR-IOR-17013568 and ChiCTR-INR-17014167.
Competing Interests: Disclosures Dr Nguyen reports being an associate editor for Stroke; compensation from Brainomix for the advisory board; compensation from Idorsia for the advisory board; pilot grant to her institution from the Society of Vascular and Interventional Neurology; compensation from Medtronic USA, Inc, for consultant services; and being a principal investigator for Route 92 Medical, Inc (no compensation). Dr Saver reports compensation from BrainQ for consultant services; stock options in Rapid Medical; stock options in Neuronics Medical; compensation from CSL Behring for consultant services; compensation from Biogen for consultant services; compensation from Roche for consultant services; compensation from Boehringer Ingelheim (prevention only) for consultant services; compensation from Abbott Laboratories for consultant services; compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; compensation from BrainsGate for consultant services; compensation from Aeromics for consultant services; stock options in MindRhythm; compensation from MIVI Neuroscience for data and safety monitoring services; and compensation from Medtronic USA, Inc, for consultant services. Dr Nogueira reports stock options in Corindus, Inc; compensation from Viz AI for consultant services; compensation from Synchron for data and safety monitoring services; compensation from Anaconda Biomed for consultant services; stock holdings in Quantanosis AI; stock options in Brainomix; compensation from NeuroVasc Technologies, Inc, for consultant services; compensation from Ceretrieve for consultant services; compensation from Imperative Care, Inc, for consultant services; compensation from Phenox, Inc, for consultant services; compensation from Brainomix for consultant services; compensation from Philips for consultant services; compensation from RapidPulse for consultant services; compensation from Cerenovus for consultant services; compensation from Hybernia for consultant services; stock options in Truvic; compensation from Brainomix for consultant services; compensation from Perfuze for consultant services; compensation from Genentech for consultant services; compensation from Stryker Corporation for consultant services; compensation from Prolong Pharmaceuticals for consultant services; compensation from Corindus Vascular Robotics for consultant services; stock options in Vesalio; compensation from Cerebrotech for consultant services; compensation from RapidPulse for consultant services; stock options in Reist/Q’Apel Medical; compensation from Astrocyte for consultant services; stock options in Perfuze; compensation from Genentech for consultant services; compensation from Phenox for consultant services; compensation from Stryker for consultant services; stock options in Viseon, Inc; compensation from Vesalio for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Anaconda for consultant services; compensation from Cerenovus for consultant services; stock options in Viz AI; stock options in Perfuze; compensation from Imperative Care for consultant services; compensation from Biogen, Inc, for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Vesalio for consultant services; stock options in Cerebrotech; grants from Cerenovus; compensation from Viz AI for consultant services; stock options in Ceretrieve; compensation from Biogen, Inc, for consultant services; stock options in Viz AI; stock holdings in Brain4Care; grants from Stryker; compensation from Ceretrieve for consultant services; stock holdings in Piraeus Medical; compensation from Shanghai Wallaby for consultant services; compensation from Perfuze for consultant services; compensation from Corindus, Inc, for consultant services; and compensation from Prolong Pharmaceuticals for consultant services. The other authors report no conflicts.