Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation

Syst Rev. 2024 Apr 30;13(1):118. doi: 10.1186/s13643-024-02532-1.

Abstract

Background: Intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the standard treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). However, the efficacy and safety of IVT before EVT in AIS-LVO patients with atrial fibrillation (AF) remains controversial. Thus, this study aims to assess the benefit of IVT plus EVT and direct EVT alone in AIS-LVO patients with AF.

Method: Relevant studies that evaluated the outcomes of IVT plus EVT versus direct EVT alone in AIS-LVO patients with AF were systematically searched in PubMed, Embase, and Cochrane Library from inception to August 10, 2023. The outcomes included successful reperfusion (score of 2b to 3 for thrombolysis in cerebral infarction), symptomatic intracerebral hemorrhage (sICH), good clinical outcome (modified Rankin scale score ≤ 2) at 3 months, and 3-month mortality.

Result: Eight eligible observational studies involving 6998 (3827 in the IVT plus EVT group and 3171 in the direct EVT group) patients with AIS-LVO complicated by AF were included. Compared with direct EVT, IVT plus EVT resulted in better 3-month clinical outcomes (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.54) and lower 3-month mortality (OR 0.78, 95% CI 0.68-0.88). However, the incidence of sICH (OR 1.26, 95% CI 0.91-1.75) and the rate of successful reperfusion (OR 0.98, 95% CI 0.83-1.17) were not significantly different between treatment modalities.

Conclusion: IVT plus EVT leads to better functional outcomes and lower mortality in AIS-LVO patients with AF. Withholding IVT plus EVT from patients with AF alone may not be justified.

Keywords: Atrial fibrillation; Intravenous thrombolysis; Ischemic stroke; Large vessel occlusion; Mechanical thrombectomy.

Publication types

  • Systematic Review
  • Research Support, Non-U.S. Gov't
  • Meta-Analysis
  • Review

MeSH terms

  • Administration, Intravenous
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Combined Modality Therapy
  • Endovascular Procedures / methods
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Ischemic Stroke*
  • Thrombectomy* / methods
  • Thrombolytic Therapy* / methods
  • Treatment Outcome

Substances

  • Fibrinolytic Agents