Stroke thrombolysis for patients with intracranial aneurysms: a nationwide cohort study

The safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with underlying unruptured intracranial aneurysms (UIAs) is unclear. This study evaluates IVT safety and efficacy in AIS patients with UIAs in routine clinical practice.

Using the 2016-2022 Nationwide Readmissions Database, we conducted a retrospective cohort study of AIS patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥ 6. Patients with a diagnosis of UIA were identified. Patients with intracranial tumors and other cerebrovascular malformations were excluded. Multivariable logistic regression assessed the association between IVT and outcomes, including routine discharge, mortality, subarachnoid hemorrhage (SAH), and intraparenchymal hemorrhage (IPH). Interaction analyses compared treatment effects between UIA and non-UIA patients.

Of 689,285 AIS patients, 11,687 (1.7%) had UIAs; 25.0% received IVT. Among UIA patients, IVT was associated with higher rates of routine discharge [adjusted OR (aOR) 2.25 (95%CI 1.95-2.59)] and lower mortality [aOR 0.64 (95%CI 0.48-0.87)]. IVT did not increase SAH risk in UIA patients [aOR 0.97 (95%CI 0.63-1.49)]. IVT was linked to higher IPH risk for UIA patients [aOR 1.34 (95%CI 1.06-1.70)], though this association was also found among non-UIA patients with a similar magnitude (p-interaction = 0.91). Compared to IVT-treated non-UIA patients, IVT-treated UIA patients were significantly more likely to experience routine discharge [OR 1.20 (95%CI 1.02-1.40)], despite having significantly higher odds of SAH [OR 1.97 (95%CI 1.19-3.26)].

Among AIS patients with UIAs, IVT was associated with better functional outcomes without excess risk of SAH. UIAs do not significantly alter the risk profile of IVT treatment.