Abstract Number: Esoc2026a153 Efficacy and Safety of Adjunctive Intra-Arterial Thrombolysis Following Endovascular Thrombectomy in Acute Ischemic Stroke: An Updated Meta-Analysis of Randomised Controlled Trials

Abstract Background and aims The efficacy of adjunctive intra-arterial thrombolysis (IAT) after endovascular thrombectomy (EVT) for acute ischaemic stroke remains uncertain due to inconsistent evidence. We reviewed international guidelines and conducted a meta-analysis of randomised controlled trials (RCTs) to evaluate the safety and effectiveness of IAT and identify subgroups most likely to benefit. Methods International stroke guidelines were systematically reviewed. For the meta-analysis, PubMed, Embase, and ClinicalTrials.gov were searched through 1 April 2025 for RCTs comparing EVT + IAT with EVT alone (PROSPERO: CRD420251031933). The primary outcome was 90-day disability-free survival (mRS 0–1); secondary outcomes were functional independence (mRS 0–2), mortality, and symptomatic intracerebral haemorrhage (sICH). Results Across 52 guidelines from 11 countries, recommendations for adjunctive IAT were highly heterogeneous. Six RCTs (n = 1807) showed that IAT significantly improved disability-free survival (OR 1.38; 95% CI:1.14–1.67), with the greatest benefits in females (OR 1.85; 95% CI:1.29–2.65), anterior circulation occlusion (OR 1.36; 95% CI:1.12–1.67), and moderate recanalisation (eTICI 2b50/2b67; OR 2.19; 95% CI 1.28–3.75). Both tenecteplase and alteplase were effective, with tenecteplase 0.125 mg/kg demonstrating the largest effect. No significant differences were observed in functional independence, mortality, or sICH. Conclusions International guidance on adjunctive IAT remains inconsistent. This updated meta-analysis provides robust evidence supporting IAT as a safe and effective adjunct to EVT, particularly for selected patient subgroups. Conflict of interest 1. Yuyan Xia: nothing to disclose. 2. Rui Pan: nothing to disclose. 3. Xue Gong: nothing to disclose. 4. Xiao Tan: nothing to disclose. 5. Haibin Wang: nothing to disclose. 6. Li Gao: This study was partially supported by the Fundamental Research Funds for the Central Universities (YG2023QNB10), and no other conflicts of interest in the past three years. 7. Hongsheng Tan: This work was supported by the Shanghai Science and Technology Commission, China under Grant 23DZ2290600; the Shanghai Jiao Tong University Trans-Med Awards Research, China under Grant 20230101; and the Technical Service Project of the Shanghai Science and Technology Commission, China under Grant DK3-0601-22-0001, and no other conflicts of interest in the past three years. Figure 1 - belongs to Results