Intra-Arterial Thrombolysis vs. Standard Treatment or Intravenous Thrombolysis in Adults with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Abstract

This analysis finds a modest benefit of intra-arterial thrombolysis over standard treatment, although it does not find a clear benefit of intra-arterial thrombolysis over intravenous thrombolysis in acute ischemic stroke patients. However, few trials, small sample sizes, and indirectness limit the strength of evidence.

Intra-arterial treatment for acute ischemic stroke: a meta-analysis

“…[21,25,27] Receiving intra-arterial therapy after IV tPA can be an unnecessary treatment associated with serious complications including intracranial hemorrhage, arterial perforation, air emboli, and adverse reactions to general anesthesia. [10,31] Inclusion of patients like these could have confounded the benefit analyses of intra-arterial therapies. From 3.4 to 18.4% of study patients evaluated here did not have large vessel obstruction at the time of intra-arterial treatment imaging [22][23][24][25][26][27]32] and the frequency of obstruction in patients not having obstruction evaluated is not known.…”

“…Intra-arterial administration of thrombolytic agents appears to be associated with a modest benefit, although their evaluation is on-going. [10,35] Some studies have shown a higher rate of arterial recanalization compared to intravenous treatments, spurring interest in this treatment modality. [35] The use of intra-arterial thrombolytic agents appears to be associated with more frequent occurrences of intracranial hemorrhage.…”

“…[35] The use of intra-arterial thrombolytic agents appears to be associated with more frequent occurrences of intracranial hemorrhage. [10] In IMS III, Synthesis Pilot, and Synthesis, intra-arterial tPA was most frequently used to remove obstructing clot. These studies were not associated with improved outcome after intra-arterial therapy.…”

“…The use of intra-arterial thrombolysis with enzymatic materials is also under active investigation and may result in similar outcomes as those found with thrombus removal devices. [10] Outcomes of studies of these treatments in patients with acute ischemic stroke have not been consistent. We performed a meta-analysis to better understand the potential benefit associated with the intra-arterial treatment of patients with acute ischemic stroke and risk factors for good or poor outcomes after treatment.…”

What is new in stroke imaging and intervention?

“…19 Recent randomised trials have shown that there is no benefit with the use of intra-arterial thrombolysis compared with IVT. 20,21 An individual patient record meta-analysis of five very recent trials (HERMES = Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke trials), all of which used CTA for patient selection and employed modern devices for clot extraction, constitutes the best evidence so far for the use of endovascular clot extraction in acute ischaemic stroke (Fig 2 ). 22 The key finding is that mechanical thrombectomy (MT) of proximal anterior circulation large artery occlusive strokes is associated with a significantly reduced disability after 90 days compared with standard medical treatment.…”