Abstract
BACKGROUND: The role of additional intravenous thrombolysis (IVT) during posterior circulation ischemic stroke (PCIS) treatment remains unclear. The aim of this study is to assess the efficacy and safety of additional IVT for PCIS. METHOD: PubMed, EMBASE, and the Cochrane library were searched to obtain studies relevant to IVT alone, endovascular treatment (EVT) alone or EVT + IVT in the treatment of PCIS from their inception through February 2025. Primary efficacy outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were the primary safety outcomes. Network meta-analysis (NMA) based on Bayesian approach was employed to assess and rank the therapeutic efficacy and safety of IVT alone, EVT alone and EVT + IVT for PCIS. Meta-regression was used to explore the source of heterogeneity. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the certainty of evidence. RESULTS: Out of 11,404, 24 non-randomized controlled trials (RCTs) and 5 RCTs were included, comprising 18,215 patients. For primary efficacy outcome, the NMA results indicated that EVT + IVT had a larger surface under the cumulative ranking curve (SUCRA) (IVT vs. EVT vs. EVT + IVT, 0.30 vs. 0.36 vs. 0.83) and higher probability of best (ProBest) (IVT vs. EVT vs. EVT + IVT, 0.10 vs. 0.21 vs. 0.69) than EVT alone and IVT alone. However, for safety outcomes, IVT alone has a larger SUCRA (sICH, IVT vs. EVT vs. EVT + IVT, 0.83 vs. 0.44 vs. 0.22) (mortality, IVT vs. EVT vs. EVT + IVT, 0.83 vs. 0.19 vs. 0.47) and higher ProBest (sICH, IVT vs. EVT vs. EVT + IVT, 0.71 vs. 0.26 vs. 0.03) (mortality, IVT vs. EVT vs. EVT + IVT, 0.73 vs. 0.12 vs. 0.14) than EVT alone and EVT + IVT. Meta-regression indicated that publication year and anatomy may be the potential source of heterogeneity. Among large vessel occlusions (LVO) patients, EVT + IVT also demonstrates a larger SUCRA and higher ProBest in mRS outcomes than IVT alone and EVT alone. CONCLUSIONS: For patients with PCIS, combined EVT and IVT has the potential to improve mRS outcomes; however, the safety profile of an additional IVT warrants further investigation. REGISTRATION AND PROTOCOL: This meta-analysis was registered in PROSPERO with registration number CRD42024556193.