Adjunctive intra-arterial thrombolysis following successful endovascular reperfusion in acute ischemic stroke: a systematic review and meta-analysis of seven randomized controlled trials.

Background: The benefits and risks of adjunctive intra-arterial thrombolysis (IAT) after successful endovascular thrombectomy (EVT) in acute ischemic stroke due to large vessel occlusion (AIS-LVO) remain uncertain. This study aimed to evaluate the efficacy and safety of IAT in this setting.

Methods: We systematically searched PubMed, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov from inception to February 2025, and reviewed abstracts from the 2025 International Stroke Conference, to identify randomized controlled trials (RCTs) comparing IAT versus placebo or best medical management in AIS-LVO patients who achieved successful reperfusion after EVT. Outcome measures included 90-day excellent (modified Rankin Scale [mRS] 0-1) and good (mRS 0-2) functional outcomes, 90-day reduced disability (≥ 1-point mRS improvement), symptomatic intracranial hemorrhage (sICH), any ICH, and 90-day mortality. A random-effects model was employed for the meta-analysis.

Results: Seven RCTs with 2131 patients (1083 assigned to IAT, and 1048 to control) were included. Compared to controls, IAT was associated with significantly higher likelihood of 90-day excellent functional outcomes (risk ratio 1.23, 95% confidence interval [CI] 1.11-1.36; I2 = 0%) and reduced disability (common odds ratio 1.20, 95% CI 1.03-1.40; I2 = 0%), but not with 90-day good functional outcomes. Risks of any ICH, sICH, and mortality were similar between groups. Subgroup analyses suggested numerically higher odds of excellent functional outcomes among patients with anterior circulation LVO or those receiving IA alteplase/tenecteplase.

Conclusions: Adjunctive IAT following successful EVT in AIS-LVO patients led to improved 90-day excellent functional outcomes and reduced disability without increasing sICH or mortality risks.