急性虚血性脳卒中における血管内血栓回収術後の動脈内テネクテプラーゼ：ランダム化比較試験のメタアナリシス

Although endovascular thrombectomy (EVT) significantly improves outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO), many patients experience incomplete recovery. Adjunctive intra-arterial thrombolysis with tenecteplase (IA-TNK) has emerged as a potential strategy to enhance distal reperfusion. This study aimed to evaluate the efficacy and safety of IA-TNK administered after successful EVT in patients with AIS.

PubMed, Web of Science, and Scopus were systematically searched from inception to May 2025. We included randomized controlled trials (RCTs) comparing IA-TNK to standard medical treatment (SMT) after successful EVT (final eTICI 2b-3) in adult patients with AIS due to LVO. Two reviewers independently screened studies, extracted data, and assessed risk of bias using RoB 2.0. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using random-effects Mantel-Haenszel models. Heterogeneity was assessed with I². Subgroup and sensitivity analyses were conducted.

Four RCTs involving 1,160 patients (591 IA-TNK; 569 SMT) were included. IA-TNK significantly increased rates of excellent functional outcome (modified Rankin Scale [mRS] 0-1 at 90 days; RR: 1.22; 95% CI: 1.04-1.44; p = 0.016; I² = 0%) without significant differences in functional independence (mRS 0-2), mortality, symptomatic intracranial hemorrhage, or any intracranial hemorrhage. Subgroup analyses suggested greater benefit in younger patients and those with cardioembolic stroke, with no significant interaction across subgroups.

Intra-arterial tenecteplase after EVT improves excellent functional outcomes without increasing hemorrhagic risk or mortality. These findings support its use as a safe and potentially effective adjunctive therapy in selected AIS patients, pending further trials.