Intra-arterial thrombolysis following mechanical thrombectomy in patients with acute ischemic stroke: A systematic review and meta-analysis

Background Adjunctive intra-arterial thrombolysis (IAT) after mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) is proposed to improve clinical outcomes. Methods We searched PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception till July 2025 for randomized controlled trials (RCTs) comparing IAT after MT versus MT alone. The analysis was carried out using RevMan 5.4 with risk ratio (RR) as the effect measure. Results Seven RCTs met the inclusion criteria. Adjunctive IAT following MT significantly improved the likelihood of achieving an excellent functional outcome (modified Rankin Scale [mRS] score of 0–1) compared to MT alone (RR: 1.23, 95% CI: 1.11–1.36). The risk of all-cause mortality was comparable between the two groups (RR: 0.98, 95% CI: 0.82–1.18). There was no significant difference in the rate of good functional outcome (mRS 0–2) (RR: 1.06, 95% CI: 0.98–1.15), any intracranial hemorrhage (ICH) (RR: 1.15, 95% CI: 0.99–1.33), or symptomatic ICH (RR: 1.17, 95% CI: 0.79–1.73). The results were consistent regardless of stroke severity and the type of thrombolytic agent used. Conclusions Our analysis suggests that IAT after MT improves the likelihood of an excellent functional outcome without increasing the risk of ICH. There was no effect on all-cause mortality and good functional outcome. Further randomized trials are needed to confirm these results and define the optimal patient population, agent, and dosing strategy for adjunctive IAT.