Efficacy and safety of rt-PA intravenous thrombolysis in the treatment of acute ischemic stroke with hyperdense middle cerebral artery sign: a systematic review

Abstract

Objective To systematically review the efficacy and safety of recombinant tissue-type plasminogen activator (rt-PA) intravenous thrombolysis in the treatment of acute ischemic stroke with hyperdense middle cerebral artery sign (HMCAS) on CT images. Methods Search online databases such as PubMed, EMBASE/SCOPUS, Cochrane Central Register of Controlled Trials (CENTRAL) and China Biology Medicine (CBM) from January 1994 to December 2014 with key words: hyperdense middle cerebral artery sign/HMCAS/hyperdense artery sign/hyperdense cerebral artery sign, ischemic stroke/cerebral infarction/brain infarction/cerebral embolism, thrombolysis/thrombolytic therapy/rt-PA/recombinant tissue plasminogen activator both in Chinese and English, to collect randomized controlled trials (RCTs) or non-RCTs about rt-PA treating patients with acute ischemic stroke and HMCAS. Two reviewers independently screened literatures according to the inclusion and exclusion criteria, extracted data, and assessed the risk of bias of included studies. Newcastle-Ottawa Scale (NOS) was used for quality assessment, and Meta-analysis was performed using RevMan 5.2 software. Results A total of 8 studies were included after excluding duplicate ones and those which did not meet the inclusion criteria from 166 articles. There were 11 373 patients, including 2455 cases complicated with HMCAS (2316 treated by rt-PA and 139 treated by placebo) and 8918 cases without HMCAS. Meta-analysis showed the occurrence of unfavorable outcome in rt-PA treatment was significantly decreased compared to placebo in HMCAS-positive patients (OR = 0.360,95%CI: 0.150-0.850; P = 0.020), while there was no statistical difference in the occurrence of symptomatic intracerebral hemorrhage (sICH) between rt-PA and placebo treatment in HMCAS-positive patients (OR = 1.640, 95%CI: 0.380-7.040; P = 0.500). Meta-analysis also showed unfavorable outcome of rt-PA treatment was significantly higher in HMCAS-positive than in HMCAS-negative patients (OR = 2.830, 95% CI: 2.550-3.150; P = 0.000), while there was no statistical difference in the occurrence of sICH after rt-PA treatment (OR = 1.090, 95% CI: 0.500-2.410; P = 0.820). Conclusions Although rt-PA intravenous thrombolysis is safe and effective in the treatment for HMCAS-positive patients with acute ischemic stroke, unfavorable outcome is easy to occur after 3 months of onset, however, the risk of symptomatic intracerebral hemorrhage is low.

DOI: 10.3969/j.issn.1672-6731.2016.01.003