The addition of intravenous thrombolysis (IVT) to endovascular thrombectomy (EVT) provides significant clinical benefits to patients who experienced acute ischaemic stroke (AIS) caused by large vessel occlusion (LVO) with large ischaemic infarcts (LII), as shown by the findings of a meta-analysis presented at the recent ISC 2025.

“Our results indicate a beneficial impact of IVT on the clinical outcomes of EVT in AIS-LVO patients with LII regarding functional outcomes and early neurological improvement,” said lead author Dr Mohamed Elfil from the University of Miami/Jackson Health System in Miami, Florida, US.

“IVT was also associated with a lower mortality rate but not with an increased risk of intracranial haemorrhage (ICH),” he added.

Elfil and his team performed a meta-analysis of relevant studies that examined the impact of IVT on the outcomes of EVT in AIS-LVO patients with LII. They used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist as well as the Cochrane Handbook of Systematic Reviews and Interventions.

 The databases of PubMed, Scopus, Web of Science, and Cochrane CENTRAL were searched from inception through 11 June 2024. Elfil and colleagues then performed their analysis with RevMan using a pooled risk ratio (RR) with a 95 percent confidence interval (CI).

Only three studies, which involved a total of 1,927 patients, met the eligibility criteria. All the studies reported on modified Rankin Scale (mRS) score of 0?2 at 3 months (831 patients in the EVT plus IVT group and 1,049 patients in the EVT-only group), demonstrating a statistically significant difference that favoured EVT plus IVT (RR, 1.48, 95 percent CI, 1.27?1.72; p<0.00001). [ISC 2025, abstract 2]

Two studies reported on mRS score of 0?3 (699 patients in the EVT plus IVT group and 831 patients in the EVT-only group), with the results of the analysis favouring EVT plus IVT (RR, 1.25, 95 percent CI, 1.11?1.41; p=0.0003).

Similarly, two studies reported findings on early neurological improvement after 24 and 36 h (699 patients in the EVT plus IVT group and 831 patients in the EVT-only group), with a statistically significant difference favouring EVT plus IVT (RR, 1.16, 95 percent CI, 1.10?1.34; p=0.03).

On the other hand, two studies reporting on successful reperfusion following EVT showed no statistically significant difference between the two treatment groups (RR, 1.01, 95 percent CI, 0.88?1.16; p=0.86).

Lower mortality

In addition, all three studies assessed mortality in 831 patients in the EVT plus IVT group and 1,049 patients in the EVT-only group. The results showed a more favourable survival benefit with EVT plus IVT (RR, 0.88, 95 percent CI, 0.77?1.00; p=0.04).

Finally, Elfil and colleagues performed a subgroup analysis and found that either intervention was not better than the other across different types of ICH.

“More studies of larger sample sizes are needed to corroborate such results,” Elfil said.

EVT is the gold standard treatment for patients with AIS-LVO, but only a few randomized controlled trials have explored EVT in AIS-LVO with LII, according to the authors.