BACKGROUND AND OBJECTIVES: The therapeutic efficacy and safety of IV thrombolysis (IVT) for patients with minor strokes remain a subject of significant debate and uncertainty. This meta-analysis aimed to assess the comparative effectiveness and safety of IVT vs nonthrombolytic standard of care (NT-SC) in minor strokes, focusing exclusively on data from randomized controlled trials (RCTs).
METHODS: A comprehensive literature search was conducted to identify RCTs evaluating IVT in minor stroke, defined as a NIH Stroke Scale (NIHSS) score =5. The primary outcome was excellent functional recovery, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (mRS 0-2 at 90 days) and safety end points, including 90-day mortality, recurrent stroke, symptomatic intracranial hemorrhage (sICH), and any ICH. The study was registered with PROSPERO (CRD42024621714).
RESULTS: The primary analysis included data from 4 RCTs that exclusively enrolled patients with minor stroke (N = 3,364; age range: 56-80 years). Secondary analyses incorporated post hoc and subgroup data on patients with minor stroke from earlier RCTs. In the primary analysis, IVT was not significantly associated with higher odds of excellent functional recovery at 90 days compared with NT-SC (mRS 0-1; odds ratio [OR] 0.85, 95% CI 0.70-1.03). IVT was significantly associated with lower odds of achieving 90-day functional independence (mRS 0-2; OR 0.71, 95% CI 0.55-0.91) and higher odds of both sICH (OR 5.22, 95% CI 1.76-15.48) and 90-day mortality (OR 2.40, 95% CI 1.23-4.67) compared with NT-SC. Subgroup analysis showed a nonsignificant association of IVT with odds of excellent functional recovery across both groups with disabling symptoms (OR 0.84, 95% CI 0.38-1.88) and nondisabling symptoms (OR 0.82, 95% CI 0.66-1.03). The pooled analysis, which incorporated nonoverlapping subgroups and post hoc data, yielded consistent findings.
DISCUSSION: The findings suggest that IVT does not confer improved functional outcomes among patients with minor strokes and can be associated with higher odds of sICH and mortality at 90 days compared with NT-SC. Since most of the included patients presented with nondisabling minor strokes, additional studies on patients with mildly disabling symptoms are warranted.
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Internal Medicine | |
| Neurology | Coming Soon... |
IV thrombolytics are a significant component for managing ischemic stroke based on current guidelines. However, appropriate patient selection is imperative due to the risks of thrombolytics. This meta-analysis evaluated thrombolytics in patients with acute stroke and NIHSS of 5 or less. The primary outcome was excellent functional recovery (mRS of 1 or less) at 90 days. From the 4 RCTs included, IV thrombolytics did not improve excellent functional recovery (OR 0.85, 95% CI 0.10-1.03). There were lower odds of 90-day functional independence (mRS 0-2, OR 0.71; 95% CI 0.55-0.91) and higher symptomatic ICH (OR 5.22, 95% CI 1.76–15.48) and 90-day mortality (OR 2.40, 95% CI 1.23–4.67) compared with standard care. This can change clinical practice because this meta-analysis suggests no benefit of IV thrombolytics in minor stroke, but there may be harm including symptomatic ICH and mortality.
This SRMA adds significant evidence to what is known that IVT for minor stroke not only does not improve outcomes but likely worsens them. This is also consistent with data that has been reported (eg TenCRAOS) for isolated CRAO. That being said, there are questions that remain such as the benefit of IVT in patients with LVO who do not get thrombectomy and posterior circulation strokes since the NIHSS is known to overemphasize anterior circulation strokes.
Important clinical area but the issue of giving thrombolysis for stroke is usually left to the stroke team.
Well done SR/MA appropriately limited to only RCTs.
Most useful for inpatient neuro-hospitalists.
When it comes to strokes, very small ones were often not included because the small risk for bleeding probably outweighed the benefit. This study looked at the benefits of IV tPA in patients with small strokes (stroke scale less than 5); the 90-day benefit was not there.