Intravenous Thrombolysis Versus Conservative Therapy in Extracranial Artery Dissection-related Ischemic Stroke: A Double-arm Meta-analysis of Functional and Safety Outcomes
Sangharsha Thapa1, Sangam Shah2, Ahmed Elmashad1, Chaitanya Medicherla1, Fawaz Al-Mufti3
1Westchester Medical Center, 2Tribhuvan University, Institute of Medicine, 3Westchester Medical Center at New York Medical College
Objective:
To compare the functional efficacy and safety outcomes of intravenous thrombolysis (IVT) versus conservative therapy in patients with acute ischemic stroke secondary to extracranial carotid or vertebral artery dissection (EAD), using a double-arm meta-analysis of observational studies published between 2003 and 2025.
Background:
Extracranial carotid and vertebral artery dissections (EAD) are important causes of ischemic stroke in younger patients. The safety of intravenous thrombolysis (IVT) in this setting remains debated due to hemorrhagic concerns and limited comparative evidence. We conducted an updated double-arm meta-analysis to reassess IVT safety and efficacy in EAD-related ischemic stroke.
Design/Methods:
We performed a systematic review and meta-analysis following PRISMA guidelines. PubMed, Embase, and Cochrane databases were searched through March 2025 for studies comparing intravenous thrombolysis (IVT) versus conservative management in ischemic stroke due to extracranial carotid or vertebral artery dissection. Data were extracted independently and analyzed using Review Manager (RevMan 5.4) and Mantel–Haenszel fixed- or random-effects models. The primary outcome was 90-day favorable functional outcome (mRS 0–2). Secondary outcomes included excellent functional outcome (mRS 0–1), intracranial hemorrhage, mortality, and recurrent stroke.
Results:
Five observational studies (n ≈ 13,300; IVT = 1,360, non-IVT = 9,925) met inclusion.
mRS 0–2 OR 0.86 (95 % CI 0.67–1.10); mRS 0–1 OR 0.78 (0.63–0.97); ICH OR 2.15 (1.01–4.56); mortality OR 3.38 (2.85–4.03); recurrent stroke OR 2.13 (0.39–11.45). Heterogeneity was low except for ICH (I² = 60 %). IVT achieved similar 90-day functional outcomes and no excess symptomatic hemorrhage or recurrent stroke compared with conservative management.
Conclusions:
Intravenous thrombolysis in extracranial carotid and vertebral artery dissection–related ischemic stroke provides comparable safety and functional outcomes to conservative therapy. These findings suggest that extracranial arterial dissection should not be considered a contraindication to IVT when standard eligibility criteria are met.
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