Intravenous thrombolysis in endovascular treatment for stroke: A systematic review meta-analysis of randomized controlled trials

Background Whether intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) should be administered in patients with acute ischemic stroke caused by large-vessel occlusion is unclear, particularly as the workflow for EVT has become faster and more consistent. Methods We performed a systematic review of randomized controlled trials (RCTs) comparing IVT + EVT with EVT alone in patients presenting within 4.5 hours of symptom onset. Results A total of 2,884 patients from seven RCTs were included. There was no significant difference in the rate of good functional outcome between the IVT + EVT and EVT alone groups (RR, 1.06; 95% CI, 0.99–1.15). All-cause mortality was also comparable between the two groups (RR, 0.96; 95% CI, 0.82–1.13). The proportion of patients with excellent functional outcome (RR, 1.07; 95% CI, 0.95–1.21) and mRS 0–3 (RR, 1.04; 95% CI, 0.98–1.10) were similar between the two groups. There were no significant differences in the rates of successful reperfusion (RR, 1.02; 95% CI, 0.99–1.06), any intracranial hemorrhage (RR, 1.12; 95% CI, 0.99–1.25), and sICH (RR, 1.22; 95% CI, 0.90–1.65) between the two groups. Subgroup analyses did not show any modification of treatment effect based on baseline NIHSS, ASPECTS, or workflow time. Conclusions Pretreatment with IVT before EVT was not associated with improvements in functional outcomes, reperfusion success, or safety compared with EVT alone. In settings where EVT can be delivered rapidly, direct EVT appears to be an effective and reasonable strategy, with no clear added value from routine bridging thrombolysis.