Abstract Body: Background: Following acute ischemic stroke (acute IS), the risk of recurrent stroke is highest in the first 90 days. It is unclear whether this risk is altered by reperfusion therapy. In this meta-analysis, we aim to evaluate the risk of early recurrent stroke and other non-stroke thrombotic events post-reperfusion therapy in acute IS.

Methods: Randomized controlled trials (RCTs) in adults aged 18 or more with acute IS comparing reperfusion treatment with best medical therapy (MED) were included. We searched the PUBMED, Embase, Cochrane Library and Web of Science databases. The studies were grouped into Endovascular thrombectomy (EVT) versus MED and intravenous thrombolysis (IVT) versus MED. We performed a meta-analysis using a random-effects model (restricted maximum likelihood) to estimate the log Peto’s odds ratio (OR) of early recurrent stroke and non-stroke thrombotic events (NSTE) (including myocardial infarction, acute coronary syndrome, deep vein thrombosis, pulmonary embolism and peripheral embolism) after reperfusion therapy compared to MED at 90 days after the onset of symptoms. This study is registered with PROSPERO (CRD42024542020).

Results: A total of 14 RCTs (n=4646) comparing EVT versus MED observed no difference in the occurrence of early recurrent stroke (5.3%, 133/2483 v.s. 4.3%, 92/2163 OR 0.39 95% CI -0.05, 0.82) (Figure 1). Eleven RCTs (n= 3426) comparing EVT versus MED reported NSTE. There was no difference in the occurrence of NSTE in the EVT arm (2.2%, 38/1705 v.s. 2.5%, 43/1714 OR -0.13 95% CI -0.63, 0.37) compared to MED (Figure 2). Nine RCTs (n=7193) comparing IVT versus MED observed no difference in the occurrence of early recurrent stroke (2%, 73/3615 v.s. 1.8%, 66/3578 OR 0.09 95% CI -0.25, 0.43) (Figure 3). Five RCTs (n=4961) comparing IVT versus MED observed no difference in the occurrence of NSTE (2%, 51/2479 v.s. 2.2%, 54/2482 OR -0.06 95% CI -0.45, 0.33). Six RCTs (n=6386) comparing different IVT agents with alteplase reported recurrent stroke. There was no difference in the occurrence of recurrent stroke in other IVT agents (6.3%, 203/3196 v.s. 5.2%, 165/3190 OR 0.3 95% CI -0.05, 0.65) compared to standard dose alteplase.

Conclusion: Reperfusion therapies (EVT±IVT) in acute IS within 24 hours of symptom onset individually or in combination were not associated with increased recurrent stroke or non-stroke thrombotic events within 90 days compared to the best medical therapy.