Intra-arterial thrombolysis as rescue therapy for incomplete reperfusion following thrombectomy: a meta-analysis

Mechanical thrombectomy (MT) is a primary treatment for acute ischemic stroke caused by large vessel occlusion. However, incomplete reperfusion is common and leads to poorer patient outcomes. Intra-arterial thrombolysis (IAT) is a potential rescue therapy, but its efficacy and safety remain controversial.

A comprehensive literature search was performed across PubMed, Scopus, Web of Science, and Cochrane Library up to January 2025. The search included terms related to stroke, thrombectomy, thrombolysis, and intra-arterial. Studies comparing IAT as rescue therapy following MT with MT alone in patients with incomplete reperfusion were included. The primary outcome was functional independence (modified Rankin Scale [mRS] score of 0-2 at 90 days). Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model. This meta-analysis followed PRISMA guidelines and was registered with PROSPERO (CRD420251063825).

Seven studies, totaling 1893 patients (374 in MT + IAT; 1519 in MT alone) were included. Pooled analysis indicated that IAT as a rescue therapy was associated with significantly higher odds of functional dependence at 90 days (OR 1.40, 95% CI 1.06-1.83; p = 0.017) and lower 90-day mortality (OR 0.69, 95% CI 0.49-0.98; p = 0.036). There was no statistically significant increase in the risk of intracranial hemorrhage (OR 0.72, 95% CI 0.46-1.11; p = 0.132) or symptomatic intracranial hemorrhage (OR 1.10, 95% CI 0.59-2.03; p = 0.768) associated with IAT.

In patients with incomplete reperfusion after MT, IAT as rescue therapy improved functional outcomes and reduced mortality within 90 days, without increasing the risk of ICH or sICH.