Abstract Body: Introduction:
Stroke is a leading cause of disability and mortality worldwide, with thrombolysis as a critical treatment. Patients in Low- and Middle- Income countries (LMIC) are disproportionately affected, however, the effectiveness and outcomes of thrombolysis in these regions have been less explored.

Objective:
To assess the safety and efficacy of thrombolysis in patients with ischemic stroke in LMIC.

Design/Methods:
A systematic search was performed in PubMed, Embase, SCOPUS, WOS and Global Index Medicus for studies conducted up to April 2024. Studies aiming to assess the outcomes of thrombolysis after ischemic stroke in LMIC were selected. Outcomes of interest included functional independence (90-day mRS 0-2), symptomatic intracerebral hemorrhage (sICH) and all-cause mortality at 90 days. Quality assessment was performed using Cochrane Risk of bias 2 tool for randomized trials and NewCastle-Ottawa scale for observational studies. A single-arm and a random effects model meta-analysis of proportions were conducted, using the I2 statistics to measure the statistical heterogeneity.

Results:
A total of 1,865 studies were screened, of which 96 studies met the inclusion criteria, representing 849,280 patients who received thrombolysis for ischemic stroke. Seven randomized controlled trials (RCTs) were included and analyzed independently. The majority of the studies used Alteplase as the thrombolytic agent, followed by Tenecteplase, Recombinant human prourokinase and Reteplase. Eight studies evaluated low dose compared to the standard dose of alteplase. For the meta analysis, articles that included the administration of standard dose of 0.9 mg/kg alteplase within a 4.5-hour time window, were considered. The pool proportion of patients with functional independence at 90 days was 58% CI 95% [51%, 64%]. Pooled proportions for sICH (ECASS III definition) and 90-day mortality were 5% CI 95% [4%,6%] and 10% CI 95% [8%,12%], respectively. However, results show high heterogeneity. Quality assessment showed low to medium risk of bias.

Conclusions:
Thrombolysis in LMIC may have similar safety and effectiveness outcomes when used with standard dose and treatment within 4.5 hours.