Adjunctive Intraarterial Thrombolysis after Thrombectomy in Large Vessel Occlusion Stroke: A Meta-Analysis of RCTs.

Background and purpose: Adjunctive intraarterial (IA) thrombolysis after endovascular thrombectomy may improve clinical outcomes in patients with large vessel occlusion (LVO) stroke possibly due to improvement in microvascular reperfusion.

Methods: We conducted a meta-analysis of randomized controlled trials (RCTs) evaluating IA thrombolysis with tenecteplase, alteplase or urokinase in anterior or posterior circulation LVO stroke after successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3). Efficacy outcomes were excellent functional outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2) and recovery without any disability (mRS 0) at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (ICH), any ICH and death. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using random-effects models.

Results: Seven RCTs (n = 2,130; 2022-2025) were included. IA thrombolytic drugs used were alteplase, tenecteplase and urokinase with doses ranging from 10 % to 50% of recommended IV dosage. IA thrombolysis significantly improved excellent functional outcome (mRS 0-1: OR 1.45, 95% CI 1.19-1.76) and recovery without any disability (mRS 0: OR 1.34, 95% CI 1.09-1.64), without safety risks (symptomatic ICH: 5.05% with IA thrombolytics vs. 4.49% in standard). Paradoxically, there was no difference in functional independence (mRS 0-2) (OR 1.09, 95% CI 0.99-1.20). Additionally, tenecteplase or alteplase at doses equivalent to 25% or 50% of recommended IV dosage significantly improved excellent functional outcome.

Conclusions: IA thrombolysis offered immediately following EVT with successful reperfusion improved excellent functional outcome and recovery without disability at 90 days with an acceptable safety profile.