Clinical outcomes after intravenous thrombolysis for acute ischemic stroke in low- and middle-income countries: a pooled analysis of 67,917 patients and systematic review

Stroke is a leading cause of disability and mortality worldwide. Patients in low- and middle-income countries (LMICs) are disproportionately affected, yet thrombolysis outcomes in these settings are underexplored. We searched PubMed, Embase, Scopus, Web of Science, and Global Index Medicus through April 2024. Outcomes were 90-day functional independence (mRS 0–2), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Risk of bias used Cochrane RoB 2 and ROBINS-I; random-effects meta-analyses estimated pooled proportions with I2. Of 1,865 records screened, 79 studies (67,917 patients; 24 countries) were included. Most used alteplase; others examined tenecteplase, recombinant prourokinase, or reteplase; eight compared low- vs standard-dose alteplase. Pooled estimates were functional independence 63% (95% CI, 58–67), sICH 4% (95% CI, 3–5), and mortality 8% (95% CI, 6–10). Functional independence was similar across continents; sICH was lowest in Asia, mortality lowest in Africa. Heterogeneity was high, partly explained by baseline stroke severity and study size. Overall risk of bias was low to moderate. Standard-dose thrombolysis within 4.5 hours in LMICs shows efficacy and safety comparable to reports from high-income countries, with regional variation in safety and mortality. These results support broader implementation of thrombolysis in resource-limited settings to reduce global stroke disparities.