Safety and Efficacy of Intravenous Tirofiban as Antiplatelet Premedication for Stent-Assisted Coiling in Acutely Ruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE:Stent-assisted coiling of intracranial aneurysms requires antiplatelet therapy, typically aspirin and clopidogrel to prevent thromboembolic complications. There is a substantial concern that tirofiban may increase the risk of hemorrhage when used as an antiplatelet premedication in ruptured intracranial aneurysms. Our aim was to evaluate the safety and efficacy of intravenous tirofiban administration, instead of oral dual antiplatelet agents, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.MATERIALS AND METHODS:We conducted a retrospective review of a data base 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. 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.CONCLUSIONS:In our study, 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.

Results from the International Subarachnoid Aneurysm Trial showed that the endovascular management of intracranial aneurysm is a safe, effective, and sometimes preferable treatment option.¹ However, endovascular treatment of ruptured wide-neck aneurysms is still a challenge to neurointerventionalists because of the controversy surrounding the use of stent placement as an adjuvant therapy for the coiling of acutely ruptured aneurysms, due to the need for antiplatelet medications. Stent-assisted procedures are particularly prone to thromboembolic complications, with a reported rate of thromboembolic events of 7%–15% during stent-assisted coiling.^2–4 Therefore, there is a need for preoperative antiplatelet therapy with optimal anticoagulation during the procedures, even with subarachnoid hemorrhage. However, there is no consensus about when and how patients should be loaded with antiplatelet medication before the procedure.Glycoprotein IIb/IIIa antagonists have attracted attention for the prevention or treatment of thromboembolism during coiling of intracranial aneurysms,^5–7 but the increased risk of intracranial hemorrhage following glycoprotein IIb/IIIa inhibition remains a substantial concern. Moreover, the safety and efficacy data regarding the use of tirofiban in endovascular aneurysm treatment are lacking.The objective of our study was to evaluate the safety and efficacy of intravenous tirofiban, instead of clopidogrel and aspirin, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.