Systematic review and meta-analysis of intra-arterial tenecteplase after endovascular thrombectomy for acute ischemic stroke

BACKGROUND: Despite the fact that a large proportion of patients with acute ischemic stroke (AIS) who undergo endovascular thrombectomy (EVT) for large vessel occlusion (LVO) achieve successful recanalization, they continue to experience poor functional outcomes due to microvascular failure. Adjunctive intra-arterial tenecteplase (IA-TNK) has been proposed as a promising strategy to address this phenomenon of futile recanalization. OBJECTIVE: To evaluate the effectiveness and safety of intra-arterial tenecteplase (IA-TNK) after successful EVT in ischemic stroke. METHODS: We performed a comprehensive search of seven databases for clinical trials of IA-TNK after successful EVT for AIS. Eligible studies compared combined IA-TNK and EVT versus EVT only. Data were pooled using random-effects models, risk of bias was assessed with RoB-2 and RoB-1, and certainty of evidence was graded using GRADE. RESULTS: Overall analysis showed that IA-TNK administered after successful EVT was associated with significantly higher rates of mRS 0-1 compared to control (risk difference [RD] = 0.08, 95% CI [0.02, 0.14], p = 0.004; I = 0%). The number needed to treat was 13. Subgroup analysis revealed some benefits across different TNK dosing strategies. There was no significant increase in symptomatic intracranial hemorrhage (sICH) (RD = 0.02, 95% CI [-0.01, 0.05], p = 0.13) or mortality (RD = -0.02, 95% CI [-0.07, 0.02], p = 0.36). CONCLUSION: Adjunctive IA-TNK after successful EVT is associated with significant improvement in functional outcomes without increasing the risk of sICH or mortality. These findings suggest that IA-TNK may be considered as promising therapy to overcome microvascular failure in patients achieving successful EVT.