Intravenous and intra-arterial thrombolysis for acute ischemic stroke following interventional cardiac procedures: A systematic review and narrative synthesis

Background Acute ischemic stroke is a rare but potentially devastating complication of interventional cardiac procedures, and evidence on thrombolysis remains limited. Objective To systematically review intravenous and intra-arterial thrombolysis (IVT and IAT) for ischemic stroke during or after cardiac procedures, focusing on neurological, functional, mortality, and haemorrhagic outcomes. Design Systematic review and narrative synthesis. Methods The review followed PRISMA guidelines and was prospectively registered in PROSPERO (CRD420261287481). PubMed, Scopus, and EMBASE were searched from inception to January 2026. Studies reporting periprocedural ischemic stroke treated with IVT and/or IAT were included. Prespecified outcomes were favourable functional outcome (modified Rankin Scale score 0–2 at approximately 90 days), all-cause mortality, and symptomatic intracranial haemorrhage; neurological improvement/recovery was additionally summarised post hoc. Results Twenty-four studies including 85 thrombolysis-treated patients were included, predominantly case reports and small case series. Exact age was available for 38 patients (median 72 years, IQR 61.3–78.8) and sex for 69 (59.4% male). TAVI/TAVR was the most frequent setting (33/85, 38.8%). Stroke occurred during or immediately after the intervention in 21/38 patients (55.3%) with precise timing; large-vessel occlusion was identified in 33/47 (70.2%) with extractable vascular imaging data. Favourable functional outcome was reported in 11/18 patients (61.1%) with compatible approximately 90-day mRS data. Post-hoc neurological improvement/recovery was separately ascertainable in 43 patients and was reported in 33/43 (76.7%). All-cause mortality occurred in 9/68 (13.2%), major or clinically significant bleeding in 8/85 (9.4%), intracranial haemorrhage/haemorrhagic transformation in 6/85 (7.1%), and symptomatic intracranial haemorrhage in 1/35 (2.9%). Conclusion Thrombolysis has been reported across heterogeneous cardiac procedural settings, but case-report predominance and substantial clinical and outcome heterogeneity preclude reliable estimates of effectiveness and safety.