Intravenous thrombolysis for ischemic stroke in the posterior circulation: A systematic review and meta-analysis

J Stroke Cerebrovasc Dis. 2024 May;33(5):107641. doi: 10.1016/j.jstrokecerebrovasdis.2024.107641. Epub 2024 Feb 21.

Abstract

Objectives: Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis.

Methods: A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R.

Results: Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively).

Conclusions: IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window.

Keywords: Acute ischemic stroke; Basilar artery occlusion (BAO); Intravenous thrombolysis (IVT); Meta-analysis; Posterior circulation; Posterior circulation strokes (PCS).

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Intravenous
  • Aged
  • Aged, 80 and over
  • Disability Evaluation
  • Female
  • Fibrinolytic Agents* / administration & dosage
  • Fibrinolytic Agents* / adverse effects
  • Functional Status
  • Humans
  • Infusions, Intravenous
  • Intracranial Hemorrhages / chemically induced
  • Intracranial Hemorrhages / mortality
  • Ischemic Stroke* / diagnosis
  • Ischemic Stroke* / drug therapy
  • Ischemic Stroke* / mortality
  • Ischemic Stroke* / physiopathology
  • Male
  • Middle Aged
  • Recovery of Function*
  • Risk Assessment
  • Risk Factors
  • Thrombolytic Therapy* / adverse effects
  • Thrombolytic Therapy* / mortality
  • Time Factors
  • Time-to-Treatment*
  • Treatment Outcome

Substances

  • Fibrinolytic Agents