Abstract WP002: Safety and Efficacy of Intra-Arterial Thrombolysis After Endovascular Thrombectomy for Large-Vessel Occlusion: A Dose-Wise Network Meta-analysis of Randomized Trials

Background: The benefit of adjunct intra-arterial (IA) thrombolysis post endovascular thrombectomy (EVT) for acute ischemic stroke remains unclear. We aim to compare the efficacy and safety of IA thrombolytic agents used in post-EVT, with particular attention to dose variation. Methods: We included randomized controlled trials of adult patients with large-vessel occlusion stroke that compared EVT alone with EVT plus IA thrombolysis. PubMed, Scopus, Embase, and the Cochrane Library were searched for relevant studies (up to 10/08/2025). The primary outcome was excellent functional recovery (modified Rankin Scale mRS 0–1 at 90 days). Safety outcomes were intracerebral hemorrhage (ICH) and 90-day mortality. Odds ratios were calculated using a random-effects frequentist network meta-analysis with the DerSimonian Laird estimator. Language refinement was assisted by ChatGPT (OpenAI, GPT-5). Results: Eight RCTs (n=2, 148) informed functional independence (mRS 0–1 at 90 days). Compared with EVT alone, EVT plus intra-arterial alteplase 0. 225 mg/kg significantly improved functional independence (OR 1. 98, 95% CI 1. 35–2. 92, p=0. 0005), and EVT plus Tenecteplase 0. 125 mg/kg also showed benefit (OR 1. 90, 95% CI 1. 12–3. 23, p=0. 017). Other regimens did not achieve statistical significance. For safety, seven RCTs (n=1, 844) demonstrated no increased risk of intracerebral hemorrhage with IA agents (e. g. , alteplase OR 0. 27, 95% CI 0. 03–2. 15; urokinase OR 1. 00, 95% CI 0. 43–2. 35), while IA tenecteplase 0. 0625 mg/kg showed a nonsignificant trend toward higher ICH (OR 1. 76, 95% CI 0. 94–3. 28; p=0. 076; I²=0%). Six RCTs (n=1, 804) demonstrated no significant mortality difference across IA thrombolysis regimens compared with EVT alone. Heterogeneity and inconsistency were low across analyses (I² = 0%). Conclusions: Adjunctive IA Alteplase and Tenecteplase after EVT improved functional recovery with no increase in ICH or mortality, and higher dose Tenecteplase appeared to yield a superior outcome compared to lower dose, underscoring the need for larger trials to refine optimal regimens. Keywords: Endovascular thrombectomy, Intra-arterial thrombolysis, Acute ischemic stroke