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IVT for Minor Stroke

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

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Year of Publication: 2024

Authors: Yang Zhang; Tian Lv; Thanh N. Nguyen; Simiao Wu; Zhi Li; Xue Bai; Dan Chen; Chuansheng Zhao; Wanyi Lin; Shiqin Chen; Yi Sui

Journal: Stroke

Citation: Stroke. 2024;55:883–892. DOI: 10.1161/STROKEAHA.123.045495

Link: https://www.ahajournals.org/doi/10.1161/STROKEAHA.123.045495

PDF: https://www.ahajournals.org/doi/epub/10....EAHA.123.045495

Clinical Question

Does intravenous thrombolysis with alteplase improve functional outcomes compared with best medical therapy in patients with acute minor ischemic stroke (NIHSS 0–5)?

Bottom Line

Meta-analysis of 20 studies (13,397 patients): IVT with alteplase does NOT improve excellent outcome (mRS 0-1) vs BMT in minor stroke NIHSS ≤5 (82.89% vs 80.90%; OR 1.10; 95% CI 0.89-1.37). IVT substantially increases sICH (1.61% vs 0.12%; OR 7.48; P<0.001) and hemorrhagic transformation (6.56% vs 1.54%; OR 4.73; P<0.001). RCTs alone: OR 0.87 (0.60-1.27). No subgroup showed benefit. Supports BMT (especially DAPT) over alteplase for minor stroke.

Major Points

  • No benefit of IVT on mRS 0-1: 82.89% vs 80.90% (OR 1.10; 95% CI 0.89-1.37; P=0.274). RCTs only: OR 0.87 (0.60-1.27).
  • 7.5x increased sICH: 1.61% vs 0.12% (OR 7.48; 95% CI 3.55-15.76; P<0.001).
  • 4.7x increased hemorrhagic transformation: 6.56% vs 1.54% (OR 4.73; 2.40-9.34; P<0.001).
  • Higher early neurological deterioration: 4.81% vs 2.97% (OR 1.81; 1.17-2.80; P=0.007).
  • No mortality difference: 0.85% vs 1.05% (OR 0.67; 0.39-1.15).
  • No subgroup showed IVT benefit: nondisabling, antiplatelet comparison, LVO exclusion, time window — all consistent.
  • DAPT noninferior to IVT per ARAMIS and PRISMS with fewer hemorrhagic complications.
  • Largest meta-analysis on topic: 13,397 patients (3 RCTs + 17 observational), 20 studies.
  • All sICH definitions consistent: ECASS II OR 7.76, ECASS III OR 4.22, NINDS OR 10.90.
  • Knowledge gap: no tenecteplase or urokinase data. TEMPO-2 ongoing.

Design

Study Type: Systematic review and meta-analysis

Randomization:

Blinding: N/A (meta-analysis)

Enrollment Period: Literature search through August 10, 2023

Follow-up Duration: 90 days (across included studies)

Centers: Multiple (20 studies)

Countries: Multiple (China, US, Australia, etc.)

Sample Size: 13397

Analysis: Random effects (I²≥50%) or fixed effects. Adjusted ORs preferred. Stata 17.0. MOOSE + PRISMA 2020. PROSPERO CRD42023445856.

Inclusion Criteria

  • Adults (≥18 years) with acute minor ischemic stroke (NIHSS 0–5)
  • Eligible for thrombolysis within 4.5 hours after onset
  • Received either IV alteplase or best medical therapy
  • Randomized controlled trials or observational studies

Exclusion Criteria

  • No control group
  • Received endovascular thrombectomy or bridging therapy
  • Case reports, guidelines, reviews, or conference reports
  • Definitions of minor stroke or outcomes not meeting criteria
  • Flawed study design or low quality

Baseline Characteristics

CharacteristicControlActive

Arms

FieldIntravenous thrombolysis (IVT)Control
InterventionIntravenous alteplase administered within 4.5 hours of symptom onsetAntiplatelets, anticoagulants, statins, blood pressure and glucose control, and other secondary prevention measures per guidelines (excluding IVT)
Duration

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Excellent functional outcome (mRS 0–1 at 90 days)PrimaryReferenceOR 1.10 (95% CI 0.89–1.37)
mRS 0–2 at 90 daysSecondaryReferenceOR 1.16 (95% CI 0.95–1.43)1.16
MortalitySecondaryReferenceOR 0.67 (95% CI 0.39–1.15)0.67
Recurrent strokeSecondaryReferenceOR 0.89 (95% CI 0.57–1.38)0.89
Recurrent ischemic strokeSecondaryReferenceOR 1.09 (95% CI 0.68–1.73)1.09
Early neurological deteriorationAdverseReferenceOR 1.81 (95% CI 1.17–2.80)1.81
Symptomatic intracranial hemorrhageAdverseReferenceOR 7.48 (95% CI 3.55–15.76)7.48
Hemorrhagic transformationAdverseReferenceOR 4.73 (95% CI 2.40–9.34)4.73

Subgroup Analysis

No difference in functional outcome between IVT and BMT in patients with nondisabling deficits or those on antiplatelet therapy.

Criticisms

  • Heterogeneity in study designs and patient selection across included studies
  • Lack of patient-level data limits ability to adjust for confounders
  • Potential publication bias

Funding

Not specified in the main text; see funding disclosures in original article

Based on: IVT for Minor Stroke (Stroke, 2024)

Authors: Yang Zhang; Tian Lv; Thanh N. Nguyen; Simiao Wu; Zhi Li; Xue Bai; Dan Chen; Chuansheng Zhao; Wanyi Lin; Shiqin Chen; Yi Sui

Citation: Stroke. 2024;55:883–892. DOI: 10.1161/STROKEAHA.123.045495

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