Adjunctive intraarterial thrombolysis in endovascular thrombectomy: a systematic review and meta-analysis

Objective To evaluate the safety and efficacy of intra-arterial
thrombolysis (IAT) as an adjunct to endovascular thrombectomy (EVT) in
ischemic stroke, we performed a systematic review and meta-analysis of the
literature. Methods Searches were performed using Medline, Embase, and
Cochrane databases for studies that compared EVT to EVT with adjunctive
IAT (EVT+IAT). Safety outcomes included symptomatic intracerebral
hemorrhage (sICH) and mortality at three months. Efficacy outcomes
included successful reperfusion (Thrombolysis in Cerebral Infarction score
of 2b to 3), and functional independence, defined as a modified Rankin
Scale score of 0 to 2 at three months. Results Five studies were
identified that compared combined EVT+IAT with alteplase or urokinase
to EVT-only, and were included in the random effects
meta-analysis. There were 1693 EVT patients, including 269 patients
treated with combined EVT+IAT and 1424 patients receiving EVT-only. Pooled
analysis did not demonstrate any differences between EVT+IAT and EVT-only
in rates of sICH (OR: 0.61, 95% CI: 0.20-1.85; P=0.78), mortality (OR:
0.77, 95% CI: 0.54-1.10; P=0.15), or successful reperfusion (OR: 1.05, 95%
CI: 0.52-2.15; P=0.89). There was a higher rate of functional independence
in patients treated with EVT+IAT, although this was not statistically
significant (OR: 1.34, 95% CI: 1.00-1.80; P=0.053). Conclusions Adjunctive
IAT appears to be safe. In specific situations, neurointerventionists may
be justified in administering small doses of intraarterial alteplase or
urokinase as rescue therapy during EVT.