Intravenous Thrombolysis in Extracranial Arterial Dissection Stroke: A Meta-Analysis

Extracranial arterial dissection (EAD) is a leading non-atherosclerotic cause of ischemic stroke in adults under 45 years of age. Intravenous thrombolysis (IVT) is central to acute stroke care, but its use in EAD remains contentious. We performed an updated meta-analysis of IVT versus conservative therapy in EAD-related stroke.

We searched PubMed, Embase, and the Cochrane Library from inception through August 2026 per PRISMA 2020 (PROSPERO: CRD420261296521). Co-primary outcomes were excellent (modified Rankin Scale (mRS) 0-1) and favorable (mRS 0-2) 90-day recovery; secondary outcomes were symptomatic intracranial hemorrhage (sICH), mortality and recurrent stroke.

Five studies met the criteria (11,285 patients; 1,410 IVT, 9,875 non-IVT); no new studies were identified. Crude analyses showed lower odds of excellent recovery (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.63-0.97), no difference in favorable recovery (OR 0.86, 95% CI 0.67-1.10) and higher odds of sICH (OR 2.15, 95% CI 1.01-4.56) and mortality (OR 3.38, 95% CI 2.85-4.03) with IVT. Adjusted analyses of the two largest studies showed greater functional independence (OR 1.67, 95% CI 1.23-2.28) and home discharge (OR 1.40, 95% CI 1.01-1.92) with IVT, without excess mortality or hemorrhage.

Crude analyses suggested worse outcomes and excess mortality/hemorrhage with IVT; adjusted analyses from the largest datasets showed better functional and discharge outcomes with no safety signal, suggesting confounding by indication rather than causal harm. EAD alone should not preclude IVT in eligible patients.