Objective: To assess the utility of IV thrombolysis (IVT) treatment in patients with acute ischemic stroke (AIS) with unclear symptom onset time or outside the 4.5-hour time window selected by advanced neuroimaging.
Methods: We performed random-effects meta-analyses on the unadjusted and adjusted for potential confounders associations of IVT (alteplase 0.9 mg/kg) with the following outcomes: 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] scores 0-1), 3-month functional independence (FI; mRS scores 0-2), 3-month mortality, 3-month functional improvement (assessed with ordinal analysis on the mRS scores), symptomatic intracranial hemorrhage (sICH), and complete recanalization (CR).
Results: We identified 4 eligible randomized clinical trials (859 total patients). In unadjusted analyses, IVT was associated with a higher likelihood of 3-month FFO (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.12-1.96), FI (OR 1.42, 95% CI 1.07-1.90), sICH (OR 5.28, 95% CI 1.35-20.68), and CR (OR 3.29, 95% CI 1.90-5.69), with no significant difference in the odds of all-cause mortality risk at 3 months (OR 1.75, 95% CI 0.93-3.29). In the adjusted analyses, IVT was also associated with higher odds of 3-month FFO (adjusted OR [ORadj] 1.62, 95% CI 1.20-2.20), functional improvement (ORadj 1.42, 95% CI 1.11-1.81), and sICH (ORadj 6.22, 95% CI 1.37-28.26). There was no association between IVT and FI (ORadj 1.61, 95% CI 0.94-2.75) or all-cause mortality (ORadj 1.75, 95% CI 0.93-3.29) at 3 months. No evidence of heterogeneity was evident in any of the analyses (I 2 = 0).
Conclusion: IVT in patients with AIS with unknown symptom onset time or elapsed time from symptom onset >4.5 hours selected with advanced neuroimaging results in a higher likelihood of CR and functional improvement at 3 months despite the increased risk of sICH.
© 2019 American Academy of Neurology.
Antiplatelet Pretreatment and Outcomes in Intravenous Thrombolysis for Stroke: A Systematic Review and Meta-AnalysisG Tsivgoulis et al. J Neurol 264 (6), 1227-1235. PMID 28550481. - ReviewSince there are contradictory data regarding the association of antiplatelet pretreatment (AP) with safety and efficacy outcomes of intravenous thrombolysis (IVT) for acu …
Association of Elevated Blood Pressure Levels With Outcomes in Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis: A Systematic Review and Meta-AnalysisK Malhotra et al. J Stroke 21 (1), 78-90. PMID 30732443.s We found that elevated BP levels adversely impact AIS outcomes in patients receiving IVT. Future randomized-controlled clinical trials will provide definitive data on t …
Safety and Efficacy of Dual Antiplatelet Pretreatment in Patients With Ischemic Stroke Treated With IV Thrombolysis: A Systematic Review and Meta-AnalysisK Malhotra et al. Neurology 94 (7), e657-e666. PMID 31959709.After adjustment for potential confounders, DAPP appears not to be associated with higher risk of adverse outcomes in patients with AIS treated with IVT.
Risk of Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis in Patients With Acute Ischemic Stroke and High Cerebral Microbleed Burden: A Meta-analysisG Tsivgoulis et al. JAMA Neurol 73 (6), 675-83. PMID 27088650. - Meta-AnalysisPresence of CMB and high CMB burdens on pretreatment MRI were independently associated with sICH in patients with AIS treated with IVT. High CMB burden may be included in …
Endovascular Therapy Versus Intravenous Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-AnalysisJ Lin et al. J Neurol. PMID 31321515. - ReviewBased on our findings, EVT is considered to be more efficacious than IVT for CAD-related AIS patients. Although EVT alone tends to be safe and promising, its safety needs …