Intra-arterial thrombolytics after endovascular thrombectomy for acute ischemic stroke: A network meta-analysis of...

Endovascular thrombectomy (EVT) is the gold standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in patients meeting certain eligibility criteria. A critical challenge in this regard is the phenomenon of futile recanalization, which can be partially explained by embolism of the distal microcirculation. Thus, a few clinical trials investigated the efficacy and safety profile of intra-arterial thrombolysis (IAT) post successful EVT aiming to improve EVT's clinical outcomes without increasing the risk of hemorrhagic complications. We aim to evaluate the efficacy and safety of adjunctive IAT after successful EVT for AIS-LVO.

A systematic review and network meta-analysis (NMA) of randomized controlled trials comparing IAT (Alteplase (ALT), Tenecteplase (TNK), or Urokinase (UK)) versus EVT alone were conducted. Primary outcomes were 90-day modified Rankin Scale (mRS) 0-1, mRS 0-2, and mortality; safety outcomes included any and symptomatic intracranial hemorrhage (any ICH and sICH).

Eight trials (2564 patients) were included. EVT + TNK 0.125 mg/kg (RR 1.54, 95% CI 1.07-2.20) and EVT + ALT 0.225 mg/kg (RR 1.51, 95% CI 1.22-1.89) improved excellent outcomes (mRS 0-1) versus EVT alone. No regimen improved mRS 0-2 or mortality. EVT + TNK 0.0625 mg/kg increased the risk of any ICH (RR 1.34, 95% CI 1.08-1.66), but not the risk of sICH.

IAT, particularly with ALT 0.225 mg/kg or TNK 0.125 mg/kg, may enhance post-EVT recovery without increasing sICH risk. Larger trials are needed to confirm optimal dosing and patient selection.