Effect of intravenous thrombolysis before endovascular therapy on outcomes in acute ischemic stroke with large core: a systematic review and meta-analysis.

Objective: To investigate the effect of intravenous thrombolysis (IVT) before endovascular therapy (EVT) on outcomes in acute ischemic stroke of large core.

Methods: The studies comparing functional outcomes after EVT with and without IVT were systematically searched up to October 10th, 2023. Odds ratio (OR) was pooled using random effects model. Subgroup analysis was performed stratified by study design, country or region, study date, imaging methods and time window.

Results: Thirteen studies were included, enrolling 1717 patients. The pooled rate of functional independence in patients receiving IVT + EVT was 26% (95% CI 20% - 33%), significantly higher than 18% (95% CI 15% - 20%) in those receiving EVT alone (OR 1.55, 95% CI 1.13-2.12, P = 0.006; I²= 23.9%). In subgroup analysis, prior IVT increased the probability of functional independence in retrospective studies (OR 1.97, 95% 1.47-2.63, P < 0.00001; I² = 0). Non-Asian patients benefit from IVT before EVT for functional independence (OR 2.04, 95% 1.48-2.81, P < 0.0001; I² = 0), but Asian patients did not (OR 1.45, 95% 0.90-2.35, p = 0.13; I² = 0). The pooled rate of symptomatic intracranial hemorrhage in patients receiving IVT + EVT was 16% (95% CI 12% - 20%), inclining to be higher than 11% (95% CI 6% - 15%) in those receiving EVT alone without significant difference (OR 1.42, 0.83-2.41, P = 0.20; I²= 12%).

Conclusions: IVT before EVT might increase the probability of functional independence in non-Asian patients with large ischemic core. The results provided clinicians with additional information on selecting eligible patients for EVT.