Adjunct tirofiban after intravenous thrombolysis in acute ischemic stroke: a GRADE-guided meta-analysis of randomized...

Early platelet-mediated re-occlusion and microvascular "no-reflow" can blunt the benefits of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). Tirofiban, a short-acting GP IIb/IIIa inhibitor, may stabilize post-lysis reperfusion. Our analysis assessed the efficacy and safety of adjunct tirofiban after IVT versus IVT alone (alteplase or Tenecteplase) in patients with AIS. We conducted a meta-analysis of randomized controlled trials (RCTs) identified through searches of PubMed, Cochrane, Scopus, and Web of Science up to August 2025. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes as mean differences (MDs), each with 95% confidence intervals (CIs). Three RCTs with 1,132 patients were included. Tirofiban improved excellent outcome (64.09% vs. 54.24%, RR 1.19, 95% CI 1.07 to 1.33, P = 0.002) and functional independence (80.67% vs. 70.45%, RR 1.20, 95% CI 1.04 to 1.38, P = 0.01) and reduced poor outcome (19.32% vs. 29.54%, RR 0.61, 95% CI 0.46 to 0.81, P = 0.0006). Early neurologic improvement favored tirofiban at 24-72 h (p = 0.001) but was neutral at 5-7 days (p = 0.25). Safety did not differ for any intracranial hemorrhage (ICH) (p = 0.26), asymptomatic ICH (p = 0.75), symptomatic ICH (p = 0.68), systemic bleeding (p = 0.75), or 90-day mortality (p = 0.84). Across randomized trials, adjunct tirofiban after IVT improved 90-day functional outcomes and early neurologic recovery. For safety, no statistically significant differences were observed in any ICH, asymptomatic ICH, systemic bleeding, or 90-day mortality; however, the estimate for sICH was very imprecise and does not exclude a clinically important increase. These results are exploratory and warrant confirmation in larger, multinational RCTs before informing practice.