Adjunctive Intra-Arterial Thrombolysis Following Endovascular Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis

Despite significant advances in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS), approximately 30%-40% of patients experience futile recanalization. This meta-analysis aimed to assess the effectiveness and safety of adjunctive intra-arterial thrombolysis (IAT) following EVT in individuals with AIS.

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared IAT after EVT with standard care. A literature search was conducted across multiple databases up to March 2025. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0-1) at 90 days, functional independence (mRS 0-2), and mortality rate. Risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous variables were calculated with 95% confidence intervals.

Six RCTs comprising 1971 patients were included. Adjunctive IAT significantly increased excellent functional outcomes at 90 days (RR = 1.24 [1.12-1.39], p < 0.0001), without significant improvement in functional independence (RR = 1.04 [0.96-1.13], p = 0.34). The IAT group exhibited significantly higher EuroQol 5 dimensions scores (MD = 0.08 [0.03-0.13], p = 0.001). Mortality rates were comparable (RR = 1.01 [0.84-1.23], p = 0.89). No significant differences were observed in any intracerebral hemorrhage (RR = 1.15 [1.00-1.33], p = 0.08), symptomatic intracerebral hemorrhage (RR = 1.13 [0.76-1.68], p = 0.53), or systemic bleeding complications.

Adjunctive IAT following EVT significantly enhances excellent functional recovery and health-related quality of life after AIS, without significantly increasing hemorrhagic complications. These findings support the consideration of IAT as a complementary strategy following mechanical thrombectomy in AIS patients who present within 24 h of symptom onset.