Large vessel occlusions associated with ipsilateral high-grade extracranial internal carotid artery stenosis, also called tandem occlusions, remain under investigation for optimal management. The risk of in-stent thrombosis is heightened for those who undergo carotid stenting in conjunction with mechanical thrombectomy (MT). Tirofiban, an intravenous antiplatelet agent functioning by binding the GIIb/IIIa receptors, inhibits platelet aggregation and has been used in cases of tandem occlusions to reduce the risk of in-stent thrombosis. Unfortunately, the bleeding risk is elevated in patients who receive intraoperative antithrombotics during stenting procedures, and especially those who undergo reperfusion therapy with prior fibrinolytic therapy. We present a case of tirofiban used to reduce the risk of in-stent thrombosis during MT and stenting of a carotid terminus tandem occlusion in a 64-year-old man. We aim to compare our case with currently published data on tirofiban use during similar procedures, with regard to indications for treatment, hemorrhagic events, and functional outcomes.

Intravenous thrombolysis (IVT) is the cornerstone of reperfusion therapy for acute ischemic stroke (AIS), yet only a minority of patients achieve functional independence with vessel re-occlusion in up to one-third of cases. IVT targets fibrin but does not inhibit platelet aggregation, providing a rationale for adjunctive early platelet inhibition; so in this context tirofiban, a short-acting glycoprotein IIb/IIIa antagonist, may synergize with thrombolysis, favoring better outcome for AIS patients. We conducted a systematic review and meta-analysis up to August 2025 on MEDLINE (via PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) of RCTs assessing efficacy and safety of early intravenous infusion of tirofiban after thrombolysis in AIS. Outcomes presented as forest plot included functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality, symptomatic intracranial hemorrhage (sICH), any ICH and early neurological deterioration (END). Risk of Bias was evaluated through Cochrane RoB 2.0 tool. Five RCTs (1,428 patients) were included. At 90 days, functional independence occurred in 78.7% tirofiban-treated versus in 67.8% control patients (RR 1.22, 95% CI 1.05-1.40), with a lower number of END in tirofiban group (RR 0.35, 95% CI 0.15-0.82). Excellent outcome did not significantly differ (RR 2.72, 95% CI 0.26-27.97), as well as mortality (RR 1.07, 95% CI 0.55-2.09), overall ICH rate (RR 1.14, 95% CI 0.75-1.72) and sICH (RR 1.74, 95% CI 0.41-7.42), although an increased number of sICH was observed in tirofiban group. Tirofiban after thrombolysis may be associated with higher rates of functional independence and reduced END. However, given the very low certainty of evidence due to substantial heterogeneity, and imprecision, this meta-analysis should be interpreted as hypothesis-generating, and larger RCTs are required to confirm these findings. PROSPERO: number 1230163.

Mechanical thrombectomy (mTE) is an established standard of care for selected patients with acute ischaemic stroke. However, in the cardiac equivalent-acute coronary syndrome-current guidelines do not recommend mTE. This is primarily based on trials showing no mortality benefit from routine thrombus aspiration, along with an increased risk of stroke.

Patients with mild acute ischemic stroke (AIS) (NIHSS score ≤5) remain at substantial risk for early neurological deterioration (END) and poor functional outcomes despite receiving standard dual antiplatelet therapy (DAPT). Tirofiban, a rapid-onset glycoprotein IIb/IIIa receptor inhibitor, may reduce this risk; however, evidence in patients with mild AIS is limited.