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Safety and Efficacy of Intravenous Thrombolytic Therapy in the Extended Window up to 24 Hours: A Systematic Review and Meta-Analysis Publisher Pubmed



Aljanabi OM1 ; Jazayeri SB2, 3 ; Toruno MA3 ; Mahmood YM4 ; Ghozy S3, 5 ; Yaghi S6 ; Rabinstein AA7 ; Kallmes DF3
Authors
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Authors Affiliations
  1. 1. Department of Neurology, Baptist Health, Lexington, KY, United States
  2. 2. Sina Trauma & Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
  3. 3. Department of Radiology, Mayo Clinic, Rochester, MN, United States
  4. 4. Centeral Pharmacy, University of Kentucky Healthcare, Lexington, KY, United States
  5. 5. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
  6. 6. Department of Neurology, Brown University, Providence, RI, United States
  7. 7. Department of Neurology, Mayo Clinic, Rochester, MN, United States

Source: Annals of Clinical and Translational Neurology Published:2024


Abstract

Objective: About 25% of patients with acute ischemic stroke (AIS) present within the intravenous thrombolytic (IVT) therapeutic window of <4.5 h. This study is to elucidate the safety and efficacy of IVT in the extended therapeutic window (ETW) in patients with AIS. Methods: Using PRISMA guidelines, a systematic review was conducted using PubMed, Embase, and Scopus. A rigorous risk of bias assessment was conducted using the RoB2 tool. Rates of excellent and good functional outcome (mRS 0–1 and mRS 0–2) at 90 days, symptomatic intracranial hemorrhage (sICH), and mortality at 90 days were pooled using generalized linear mixed model and compared with controls. Meta-analyses were conducted employing random-effect models with risk ratio (RR) and 95% confidence intervals (CIs). Subgroup analysis was performed to assess the effect of imaging modalities used for patient selection. Results: Eight randomized controlled trials (n = 2221, 59% male) were included. At 90 days IVT showed higher rates of functional recovery: mRS 0–1: RR 1.21 95% CI 1.1–1.34, p < 0.001, and mRS 0–2: RR 1.11 95% CI 1.03–1.18, p = 0.004. Rate of mortality at 90 day was not different between groups: RR 1.17 95% CI 0.93–1.48, p = 0.17. However, the rate of sICH was higher among IVT group: RR 2.93 95% CI 1.53–5.6, p = 0.001. Subgroup analysis showed higher mRS 0–1 among patients who were selected based on perfusion imaging (p < 0.05). Interpretation: The use of IVT in AIS in ETW is beneficial especially with the use of perfusion imaging for patients' selection. © 2024 The Author(s). Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.
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