Intra‐Arterial Thrombolysis After Successful Thrombectomy: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials

BACKGROUND This study aims to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) to assess the efficacy and safety of intra‐arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) in patients with stroke. METHODS A systematic literature search was conducted to identify RCTs comparing IAT versus no IAT after successful EVT. The primary efficacy outcome was a modified Rankin Scale score of 0–1 at 90 days, and the primary safety outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Subgroup meta‐analyses were conducted based on expanded Thrombolysis in Cerebral Infarction (eTICI) and prior intravenous thrombolysis (IVT). Both random‐effects and common‐effect models were applied with model selection determined by the level of heterogeneity. RESULTS Six RCTs were included, comprising 990 patients in the IAT group and 981 in the control group. Meta‐analysis demonstrated that IAT following successful EVT improved the rate of disability‐free survival at 90 days, with a pooled risk ratio (RR) of 1.24 (95% CI: 1.12–1.39) and no substantial heterogeneity (I 2 = 16.0%, P = 0.31). Additionally, IAT treatment did not increase the risk of symptomatic intracranial hemorrhage (RR: 1.14 95% CI: 0.85–1.54) or 90‐day mortality (RR: 1.05 95% CI: 0.87–1.26). Subgroup meta‐analysis suggested greater benefits from IAT in patients with eTICI 2b50/67 (RR: 1.51 95% CI: 1.03–2.23) than in those with eTICI 2c/3 (RR: 1.22, 95% CI: 0.99–1.50), and in patients without prior IVT (RR: 1.33 95% CI: 1.08–1.65) compared with those who received IVT (RR: 1.17 95% CI: 0.85–1.62). CONCLUSION IAT following successful EVT improved 90‐day functional outcomes without increasing the risk of symptomatic intracranial hemorrhage or 90‐day mortality. Patients in the eTICI 2b50/67 subgroup and those without prior IVT showed a trend toward greater benefit from IAT compared with the eTICI 2c/3 subgroup and those who received IVT prior to thrombectomy.