JAMA
Adjunct tirofiban improves stroke recovery after tenecteplase
Clinical Takeaway: For patients with acute ischemic stroke who have no large or medium vessel occlusion or cardioembolic source and show inadequate early response to tenecteplase, adjunctive tirofiban may help improve 90-day recovery. These findings apply to a narrowly selected population and require confirmation in larger studies.
Despite advances in thrombolytic therapy for acute ischemic stroke, many patients show little early neurologic improvement after tenecteplase. Prior studies have suggested potential benefit from early tirofiban after thrombolysis, but its role in patients without large or medium vessel occlusion or cardioembolic source has remained uncertain.
In the randomized INSTANT trial, 359 patients at 37 hospitals in China were assigned to intravenous tirofiban or placebo 4 to 24 hours after tenecteplase if they showed no significant early neurologic improvement, neurologic worsening, or neurologic fluctuation. Oral antiplatelet therapy was started later in the tirofiban group to preserve blinding.
At 90 days, an excellent outcome, defined as modified Rankin Scale score 0 to 1, occurred in 63.8% of tirofiban-treated patients versus 52.2% of placebo-treated patients. Tirofiban also improved the ordinal distribution of modified Rankin Scale scores and health-related quality-of-life measures. Functional independence and independent ambulation were numerically higher with tirofiban but did not reach statistical significance.
Safety outcomes were reassuring overall. Symptomatic intracranial hemorrhage within 48 hours occurred in one patient in the tirofiban group and none in the placebo group, and 90-day mortality was low in both groups.
Adjunctive intravenous tirofiban after tenecteplase improved 90-day functional outcomes without increasing symptomatic intracranial hemorrhage or mortality in selected patients with acute ischemic stroke, concluded the study investigators. They added that early tirofiban may represent a potential post-thrombolysis treatment strategy in this population.
Source: INSTANT Trial Authors for the INSTANT Investigators. (2026, May 8). JAMA. Intravenous Tirofiban After Tenecteplase in Acute Ischemic Stroke