The Added Benefit of Intra‐Arterial Thrombolysis After Successful Recanalization by Endovascular Treatment: A Systematic Review and Meta‐Analysis of Randomized‐Controlled Clinical Trials
Lina Palaiodimou, Νικόλαος Παπαγεωργίου, Guillaume Turc, Benjamin Gory, Aikaterini Theodorou, Eleni Bakola, George Magoufis, Stavros Spiliοpoulos, Michael Mantatzis, Nitin Goyal, Marios Themistocleous, Amrou Sarraj, Aristeidis H. Katsanos, Urs Fischer, Andrei V. Alexandrov, Georgios Tsivgoulis
Abstract
BACKGROUND: Despite successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) with large-vessel occlusion (LVO), many patients fail to achieve excellent functional outcomes. Post-EVT intra-arterial thrombolysis (IAT) has emerged as a potential adjunctive strategy to improve microvascular reperfusion and clinical recovery. METHODS: We conducted a systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) comparing IAT plus best medical therapy (BMT) versus BMT alone in LVO-AIS patients with successful recanalization post-EVT. The primary efficacy outcome was 3-month excellent functional outcome [modified Rankin Scale (mRS)-score: 0-1]. Secondary efficacy outcomes included good functional outcome (mRS-score: 0-2) and reduced disability (mRS-score shift analysis) at 3 months. The primary safety outcome was symptomatic intracranial hemorrhage (sICH); secondary safety outcomes included any-ICH and 3-month all-cause mortality. Subgroup and network meta-analyses were performed evaluating the effects of different thrombolytic agents. RESULTS: = 0%) compared with BMT alone. Similar rates of 3-month good functional outcome, 3-month mortality, sICH and any-ICH were observed. Although no significant subgroup differences emerged, in the network meta-analysis alteplase ranked highest in efficacy [surface under the cumulative rank curve (SUCRA): 90%], followed by tenecteplase (61%) and urokinase (40%) in achieving 3-month excellent functional outcome. CONCLUSIONS: IAT improves excellent functional outcomes without compromising safety in LVO-AIS patients with successful recanalization after EVT. TRIAL REGISTRATION: The prespecified protocol of the present systematic review and meta-analysis has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO (registration ID: CRD420251035903).