Al-Janabi Omar M, Jazayeri Seyed Behnam, Toruno Michelle A, Mahmood Yamama M, Ghozy Sherief, Yaghi Shadi, Rabinstein Alejandro A, Kallmes David F
Department of Neurology, Baptist Health, Lexington, Kentucky, USA.
Sina Trauma & Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Ann Clin Transl Neurol. 2024 Dec;11(12):3310-3319. doi: 10.1002/acn3.52239. Epub 2024 Oct 29.
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.
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.
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).
The use of IVT in AIS in ETW is beneficial especially with the use of perfusion imaging for patients' selection.
约25%的急性缺血性卒中（AIS）患者在静脉溶栓（IVT）治疗窗（<4.5小时）内就诊。本研究旨在阐明IVT在AIS患者延长治疗窗（ETW）中的安全性和有效性。
按照PRISMA指南，使用PubMed、Embase和Scopus进行系统评价。使用RoB2工具进行严格的偏倚风险评估。采用广义线性混合模型汇总90天时良好和优异功能结局（改良Rankin量表[mRS] 0-1和mRS 0-2）的发生率、症状性颅内出血（sICH）以及90天时的死亡率，并与对照组进行比较。采用随机效应模型及风险比（RR）和95%置信区间（CI）进行荟萃分析。进行亚组分析以评估用于患者选择的影像学检查方式的影响。
纳入8项随机对照试验（n = 2221，59%为男性）。90天时，IVT显示出更高的功能恢复率：mRS 0-1：RR 1.21，95%CI 1.1-1.34，p < 0.001；mRS 0-2：RR 1.11，95%CI 1.03-1.18，p = 0.004。90天时两组死亡率无差异：RR 1.17，95%CI 0.93-1.48，p = 0.17。然而，IVT组sICH发生率更高：RR 2.93，95%CI 1.53-5.6，p = 0.001。亚组分析显示，基于灌注成像选择的患者中mRS 0-1更高（p < 0.05）。
在ETW中对AIS患者使用IVT是有益的，尤其是在使用灌注成像进行患者选择时。
