Intravenous thrombolysis prior to endovascular treatment for stroke: a systematic review and meta-analysis of randomized controlled trials

Whether intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) benefits patients with acute ischemic stroke and large-vessel occlusion remains uncertain. We pooled randomized trials comparing IVT + EVT with EVT alone in eligible adults presenting within 4.5 h. Outcomes were summarized as risk ratios (RRs) with 95% confidence intervals (CIs) using random-effects models. Strict modified Rankin Scale (mRS) 0–2 was also assessed using risk difference (RD), number needed to treat for benefit (NNTB), and post hoc Bayesian methods. Seven trials included 2,884 patients. Strict mRS 0–2 occurred in 741/1,448 IVT + EVT and 689/1,436 EVT-alone participants (RR, 1.07; 95% CI, 0.99–1.15). The pooled RD was + 3.08% points (95% CI, − 0.90 to + 7.05; P =.129), equivalent to 31 additional favorable outcomes per 1,000 (95% CI, 9 fewer to 71 additional) and a point-estimate NNTB of 33. The Bayesian median RD was + 2.93 points (95% credible interval [CrI], − 2.24 to + 7.72); the probabilities of any benefit and benefit of at least 1.3 points were 88.8% and 75.8%. Mortality was similar between groups (RR, 0.98; 95% CI, 0.84–1.16). Trial-defined primary symptomatic intracranial hemorrhage (sICH) occurred in 81/1,435 versus 68/1,432 participants (RR, 1.19; 95% CI, 0.87–1.63); the posterior probability of an absolute excess of at least 1 point was 22.6%. Randomized evidence did not demonstrate superiority of IVT + EVT over EVT alone. Clinically meaningful functional benefit remains plausible, whereas sICH harm remains uncertain. These findings do not establish equivalence.