Intra-arterial thrombolytics after successful recanalization in endovascular thrombectomy for large-vessel occlusion acute ischemic stroke: A comprehensive meta-analysis of randomized controlled trials.

Background: Intra-arterial thrombolytics (IAT) as adjunctive therapy for large vessel occlusion acute ischemic stroke (LVO-AIS) after successful endovascular thrombectomy (EVT) may improve outcomes. This meta-analysis evaluates the efficacy and safety of IAT in this context.

Methods: We identified randomized controlled trials (RCTs) comparing IAT versus placebo or no IAT in LVO-AIS patients with successful recanalization post-EVT, including published studies and recent conference data. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] 0-1) at 90 days. Secondary outcomes included other mRS 0-2 at 90 days, symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Pooled risk ratios (RRs) with 95 % confidence intervals (CIs) were calculated using a random-effects model; heterogeneity was assessed using the I² statistic.

Results: Six RCTs comprising 1972 patients (990 IAT, 982 control) were included. IAT was associated with a higher likelihood of excellent outcome at 90 days (RR = 1.25; 95 % CI: 1.07-1.46; p = 0.01; I² = 16 %). There were no significant differences in functional independence (mRS 0-2) (RR = 1.06; 95 % CI: 0.97-1.17; p = 0.15), sICH (RR = 1.14; 95 % CI: 0.70-1.85; p = 0.52), or 90-day mortality (RR = 1.00; 95 % CI: 0.79-1.27; p = 0.99); heterogeneity was low across these outcomes (I² = 0 %).

Conclusion: Adjunct IAT after successful EVT significantly improves excellent functional outcomes at 90 days without increasing sICH or mortality. However, its effect on broader disability outcomes is uncertain. Further trials are needed to refine patient selection.