Intravenous Alteplase Versus Best Medical Therapy for Patients With Minor Stroke: A Systematic Review and Meta-Analysis

Abstract

Background: The efficacy of thrombolysis (IVT) in minor stroke (National Institutes of Health Stroke Scale score, 0–5) remains inconclusive. The aim of this study is to compare the effectiveness and safety of IVT with best medical therapy (BMT) by means of a systematic review and meta-analysis of randomized controlled trials and observational studies. Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to IVT in minor stroke from inception until August 10, 2023. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 at 90 days. The associations were calculated for the overall and preformulated subgroups by using the odds ratios (ORs). This study was registered with PROSPERO (CRD42023445856). Results: A total of 20 high-quality studies, comprised of 13 397 patients with acute minor ischemic stroke, were included. There were no significant differences observed in the modified Rankin Scale scores of 0 to 1 (OR, 1.10 [95% CI, 0.89–1.37]) and 0 to 2 (OR, 1.16 [95% CI, 0.95–1.43]), mortality rates (OR, 0.67 [95% CI, 0.39–1.15]), recurrent stroke (OR, 0.89 [95% CI, 0.57–1.38]), and recurrent ischemic stroke (OR, 1.09 [95% CI, 0.68–1.73]) between the IVT and BMT group. There were differences between the IVT group and the BMT group in terms of early neurological deterioration (OR, 1.81 [95% CI, 1.17–2.80]), symptomatic intracranial hemorrhage (OR, 7.48 [95% CI, 3.55–15.76]), and hemorrhagic transformation (OR, 4.73 [95% CI, 2.40–9.34]). Comparison of modified Rankin Scale score of 0 to 1 remained unchanged in subgroup patients with nondisabling deficits or compared with those using antiplatelets. Conclusions: These findings indicate that IVT does not yield significant improvement in the functional prognosis of patients with acute minor ischemic stroke. Additionally, it is associated with an increased risk of symptomatic intracranial hemorrhage when compared with the BMT. Moreover, IVT may not have superiority over BMT in patients with nondisabling deficits or those using antiplatelets.

Thrombolysis Is Not Indicated for Minor Strokes If They Are Truly Nondisabling

“…In the current issue of Stroke, Zhang et al 6 report a thorough meta-analysis of existing studies assessing the value of intravenous thrombolysis for patients who present within the therapeutic window for acute stroke treatment, but who have only minor deficits that would not impact their quality of life. The meta-analysis, which included 20 studies and nearly ≈14 000 patients, confirms what individual studies had previously suggested-patients with small strokes based on the National Institutes of Health Stroke Scale (NIHSS) and in whom deficits are not disabling do not benefit from treatment with intravenous alteplase.…”