急性缺血性卒中血管内再灌注后动脉内溶栓的疗效与安全性：一项随机试验的系统评价和荟萃分析

Efficacy and safety of intra-arterial thrombolysis after endovascular reperfusion for acute ischemic stroke: a systematic review and meta-analysis of randomized trials.

作者信息

Guo Yu, Yang Guang, Ding Yuwei, Liu Chao, Shen Zhiyuan, Zhang Hengzhu, Bao Qiangji, Luo Wenmiao

机构信息

Department of Neurosurgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, China.

Department of Neurology, Kunshan Hospital of Traditional Chinese Medicine, Jiangsu, China.

出版信息

Int J Surg. 2025 Apr 25. doi: 10.1097/JS9.0000000000002404.

DOI:10.1097/JS9.0000000000002404

PMID:40277355

Abstract

OBJECTIVE

This pooled analysis aims to evaluate the efficacy and safety of intra-arterial thrombolysis (IAT) following near-complete to complete reperfusion by endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO).

METHODS

We conducted a search of PubMed, Embase, and Cochrane databases to identify randomized controlled trials (RCTs) investigating the adjunct benefit of IAT in patients with AIS-LVO who had achieved a score on the Thrombolysis In Cerebral Infarction (TICI) scale of 2b-3 after EVT. Efficacy outcomes encompassed excellent functional outcome, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days, and functional independence (mRS 0-2). Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. A network meta-analysis (NMA) was performed to evaluate the effects of different types of intra-arterial thrombolytic agents on mRS 0-1.

RESULTS

A total of 7 RCTs were included in the analysis, involving 2,128 patients. Relative risks (RR) and 95% confidence intervals (CI) were pooled using a random-effects model. The pooled results indicated that adjunctive IAT did not significantly improve the rate of functional independence (RR 1.04, 95% CI 0.96-1.13, P = 0.29). However, there was a significant increase in excellent functional outcome with adjunctive IAT (RR 1.23, 95% CI 1.11-1.36, P < 0.001). The pooled analysis did not demonstrate any differences between EVT + IAT and EVT only in rates of sICH (RR 1.23, 95% CI 0.81-1.85, P = 0.33) or 90-day mortality (RR: 0.98, 95% CI: 0.82-1.18; P = 0.86). The NMA found no significant difference in achieving mRS 0-1 among arterial adjunctive alteplase, tenecteplase, and urokinase following successful reperfusion.

CONCLUSIONS

IAT as an adjunct to successful EVT appears to enhance excellent functional outcome in patients with AIS-LVO without a significant increase in sICH and mortality.

摘要

目的

本汇总分析旨在评估血管内血栓切除术（EVT）实现近乎完全至完全再灌注后，对大动脉闭塞所致急性缺血性卒中（AIS-LVO）患者进行动脉内溶栓（IAT）的疗效和安全性。

方法

我们检索了PubMed、Embase和Cochrane数据库，以确定随机对照试验（RCT），这些试验研究了IAT对AIS-LVO患者的辅助益处，这些患者在EVT后脑梗死溶栓（TICI）量表上的评分为2b-3。疗效指标包括良好的功能结局，定义为90天时改良Rankin量表（mRS）评分为0-1，以及功能独立（mRS 0-2）。安全性指标包括症状性颅内出血（sICH）和90天时的死亡率。进行网络荟萃分析（NMA）以评估不同类型动脉内溶栓剂对mRS 0-1的影响。

结果

分析共纳入7项RCT，涉及2128例患者。使用随机效应模型汇总相对风险（RR）和95%置信区间（CI）。汇总结果表明，辅助IAT并未显著提高功能独立率（RR 1.04，95% CI 0.96-1.13，P = 0.29）。然而，辅助IAT使良好功能结局显著增加（RR 1.23，95% CI 1.11-1.36，P < 0.001）。汇总分析未显示EVT + IAT与单纯EVT在sICH发生率（RR 1.23，95% CI 0.81-1.85，P = 0.33）或90天死亡率（RR：0.98，95% CI：0.82-1.18；P = 0.86）方面存在任何差异。NMA发现，成功再灌注后，动脉内辅助使用阿替普酶、替奈普酶和尿激酶在实现mRS 0-1方面无显著差异。