The Multicentre Acute ischemic stroke imaGIng and Clinical data (MAGIC) repository: rationale and blueprint.

Background Cerebral microbleeds (CMBs) are common in acute ischemic stroke (AIS) patients. The presence of CMBs increases the risk of hemorrhagic transformation in AIS patients, and it is also closely associated with cognitive decline and even dementia. At present, there exist different opinions on the independent risk factors for CMBs, and there is no consensus on whether there are gender differences in -post-stroke CMB. Therefore, this study sought to investigate gender heterogeneity in the influencing factors for CMBs by studying male and female AIS patients. Methods This was a China-based, Single-center, retrospective review of data from 482 AIS inpatients at the Neurology Department of Hebei General Hospital (NCT05882123). Both demographic and clinical data were collected from the study subjects. Different head magnetic resonance imaging sequences were used to assess the subjects’ CMBs, white matter lesions, and old lacunar infarcts (LI). Various statistical methods, including the t-test, χ 2 test, and logistic regression, were used to analyze the gender heterogeneity of the influencing factors for CMBs in AIS patients. Results When compared with the male AIS patients, the female AIS patients were older and had higher total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, ApoA, ApoB, and fibrinogen levels. The female AIS patients also had higher National Institute of Health Stroke Scale scores and hypertension disease composition ratios. By contrast, the proportions of female AIS patients with a history of smoking and a history of alcohol consumption were both lower than the corresponding proportions of male AIS patients. These differences were all statistically significant (p < .05). There were no statistically significant differences in the incidence and severity of CMBs between the male and female AIS patients (χ 2 ＝ 0.851, 3.092, p > .05). The univariate and multivariate stepwise logistic regression analyses confirmed that age (OR = 1.074, 95% CI: 1.013–1.139, p = .016) and old LI (OR = 4.295, 95% CI: 1.062–17.375, p = .041) were independent risk factors for comorbid CMBs in the female AIS patients, while blood glucose (OR = 0.692, 95% CI: 0.494–0.968, p = .031) was an independent protective factor for comorbid CMBs in the female AIS patients. However, these factors were not found to be independent risk or protective factors for comorbid CMBs in male AIS patients. Conclusion There are gender differences in the influencing factors for CMBs in AIS patients. Age, old LIs, and blood glucose are independent risk or protective factors for comorbid CMBs in female AIS patients, although they are not associated with the risk of developing CMBs in male AIS patients.

Background and aims:Tenecteplase has recently emerged as an alternative thrombolytic agent in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO), possibly superior in achieving early reperfusion compared with alteplase. We aimed to compare the safety and efficacy of intravenous tenecteplase with intravenous alteplase for AIS patients with LVO in everyday clinical practice settings.Methods:We prospectively evaluated patients with AIS due to LVO, treated with intravenous thrombolysis (IVT) with or without mechanical thrombectomy in two tertiary stroke centers. Patients were treated with standard-dose alteplase (0.9 mg/kg) or 0.25 mg/kg tenecteplase. Safety outcomes included prevalence of symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes included averted thrombectomy, major neurological improvement at 24 h (defined as decrease in baseline NIHSS score of 8 points or greater) and functional status on discharge and on 3 months assessed by modified Rankin Scale (mRS).Results:Nineteen AIS patients with LVO received tenecteplase and 39 received alteplase. We observed a non-significant higher rate of averted thrombectomies (32% versus 18%, p = 0.243) and a non-significant higher rate of sICH (16% versus 5%, p = 0.201) in the tenecteplase group. The rate of 24 h major neurological improvement was higher in the tenecteplase group (64% versus 33%, p = 0.046) but this was marginally attenuated in multivariable analyses (adjusted OR 10.22, 95% CI: 0.73–142.98; p = 0.084). Discharge mRS, 3-months mRS, and 3-month functional independence (mRS scores of 0–2) did not differ (p > 0.2) between the two groups. The rates of 3-month mortality (11% versus 18%, p = 0.703) were similar in the two groups. No independent association between thrombolytic agent and safety or efficacy outcomes emerged in multivariable regression analyses.Conclusion:The present pilot observational study highlights that AIS patients with LVO treated with 0.25 mg/kg bolus administration of tenecteplase had increased likelihood to achieve early neurological improvement compared with AIS patients treated with alteplase, but this association was attenuated after adjustment for potential confounders. There were no significant differences in 3-month functional or safety outcomes between the two groups. This preliminary real-world observation requires independent confirmation in larger, multicenter studies.

BackgroundSilent Information Regulator 2 (SIRT2) protein inhibition has been shown to play a neuroprotective role in acute ischemic stroke (AIS) in mice. However, its role in AIS patients has not been fully understood. In this study, we aimed to analyze SIRT2 protein expression in serum exosomes of AIS and non-AIS patients, and evaluate its potential role in diagnosis and prognosis of AIS.MethodsSerum exosomes from 75 non-AIS subjects and 75 AIS patients were isolated. The SIRT2 protein levels in exosomes were analyzed using enzyme linked immunosorbent assay (ELISA). The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of the disease. The modified Rankin Scale (mRS) was employed to assess the functional outcomes of the patients at 3-months following stroke onset.ResultsThe SIRT2 protein concentration of serum exosomes were higher in AIS patients than non-AIS patients (p < 0.001). Furthermore, the receiver operative characteristic curve (ROC) demonstrated that higher serum exosome SIRT2 could differentiate AIS patients from non-AIS patients with a sensitivity of 81.3% and a specificity of 75.3%. The area under the curve was 0.838 (95% CI: 0.775, 0.902). Additionally, higher SIRT2 concentration of serum exosomes were associated with NIHSS ≥ 4 (p < 0.001) and mRS ≥ 3 (p = 0.025) in AIS patients. The ROC analysis showed SIRT2 could discriminate stroke with NIHSS ≥ 4 from mild stroke (NIHSS < 4) with a sensitivity of 75.0% and a specificity of 69.6%. The area under the curve was 0.771 (95% CI: 0.661,0.881). Similarly, the test showed SIRT2 could differentiate between AIS patients with mRS ≥ 3 from those with mRS < 3 with a sensitivity of 78.3% and a specificity of 51.9%. The area under the curve was 0.663 (95% CI: 0.531,0.796). The logistic regression analysis revealed that SIRT2 concentration in serum exosomes can independently predict the diagnosis of AIS (odd ratio = 1.394, 95%CI 1.231–1.577, p < 0.001) and higher NIHSS scores (≥ 4) (odd ratio = 1.258, 95%CI 1.084–1.460, p = 0.002). However, it could not independently predict the prognosis of AIS (odd ratio = 1.065, 95%CI 0.983–1.154, p = 0.125).ConclusionThe elevation of SIRT2 in serum exosomes may be a valuable biomarker of AIS, which may be a potential diagnostic tool to facilitate decision making for AIS patients.

Background- Significant numbers of acute ischemic stroke (AIS) patients recover with timely-administered intravenous tissue plasminogen activator (IV-TPA). However, rates and extent of recovery remain variable. Considering scarce and costly resources, early identification of reliable predictors for functional outcomes is important for planning rehabilitation strategies. We hypothesized that venous drainage would be impaired on the side of cerebral hypoperfusion due to acute occlusion of internal carotid or middle cerebral artery. The 2 internal cerebral veins (ICV) drain the deep parts of hemispheres and run backward to form great cerebral vein. Since ICVs are consistently seen on CT angiography (CTA), parallel and run very close to each other, even minor asymmetry in their filling can be easily diagnosed. ICV asymmetry in pre-TPA CTA can change in patients achieving arterial recanalization, rendering it less useful for predicting the long-term outcomes. Thus, we aimed at evaluating whether the presence of ICV asymmetry on follow-up CTA can predict the final outcome. Methods- Data from consecutive AIS patients treated with IV-TPA, in a standardized protocol, from Jan2007 to March2010 were included in a prospective registry at our tertiary center. In this study, we excluded posterior circulation strokes. Significant proportion AIS patients undergo CTA on day 2 after IV-TPA to assess the status of arterial patency. ICV asymmetry was assessed by 2 independent stroke neurologists/ neuroradiologists, blinded to patient data or outcomes. Functional outcomes were assessed by modified Rankin Scale (mRS) at 3-months, dichotomized as good outcome (mRS 0-1) and poor outcome (mRS 2-6). Data were analyzed for the early predictors of function outcome. Results- Of the total of 2238 patients admitted during the study period, 226 (10.1%) with anterior circulation AIS treated with intravenous thrombolysis were included. Median age was 65yrs (range 19-92), 63% males and median National Institute of Health Stroke Scale (NIHSS) 16points (range 4-32). Hypertension was the commonest vascular risk factor in 144 (76%) while 63 (33%) patients suffered from atrial fibrillation (AF). Overall, 108 (47.8%) patients achieved poor functional outcome at 3-months. ICV asymmetry could be assessed only in 103 (45.5%) patients on their follow up CTA films. Admission NIHSS score (OR1.08;95%CI 1.001-1.157,p=0.048) and ICV asymmetry on follow-up CT scan (OR 23.9;95%CI 5.15-63.99,p &lt;0.0001) were associated with poor outcome at 3-months. Conclusion- Presence of the asymmetry of internal cerebral veins on the follow up CT angiography in acute ischemic stroke patients treated with IV-TPA can be used as an early predictor of poor functional outcome.

ObjectiveThe aim of this study is to examine the potential risk factors contributing to early neurological deterioration (END) following intravenous thrombolysis in patients diagnosed with acute ischemic stroke (AIS).MethodsClinical data was gathered from AIS patients who underwent intravenous thrombolysis at the Affiliated People’s Hospital of Jiangsu University between January 2020 and December 2023. Patients were subsequently categorized into two groups based on the occurrence of END within 24 h post-thrombolysis: the END group and the non-END group. A comparative analysis of the clinical data from both groups was conducted. The application of Multivariate Logistic regression facilitated the identification of independent risk factors and the construction of a nomogram prediction model.ResultsThe study encompassed a total of 249 AIS patients, with 32 patients (12.9%) developing END. The multivariate analysis revealed that NIHSS Score immediately after thrombolysis (p < 0.001), the Trial of Org 10172 in Acute Stroke Treatment (TOAST) typing of large artery atherosclerosis (p = 0.025), and a prior history of diabetes (p = 0.023) were independent risk factors for the development of END post-thrombolysis. A nomogram was constructed to generate the ROC curve, and the AUC value was 0.809 (95% CI, 0.732–0.885).ConclusionThis nomogram, which demonstrates good discrimination and high predictive value, identifies NIHSS score immediately after thrombolysis, TOAST classification of large artery atherosclerosis, and a history of diabetes as independent risk factors for early neurological deterioration (END) in acute ischemic stroke (AIS) patients receiving intravenous thrombolysis.

BACKGROUND: Intracranial aneurysm was considered an exclusion criteria for intravenous(IV) thrombolysis in acute ischemic stroke in both NINDS and ECASS III studies, possibly due to a hypothetical increase in the risk of bleeding from the aneurysm rupture; however, there is limited data available on whether IV thrombolysis is unsafe for acute ischemic stroke patients with incidental brain aneurysms and to the best of our knowledge, no data is available on the safety of combination of IV and intra-arterial (IA) thrombolysis in those patients. AIM: To find out the safety of acute reperfusion therapy in acute ischemic stroke patients who harbor intracranial aneurysm. METHODS: We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with IV thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with evidence of unruptured intracranial aneurysm on cerebrovascular images prior to acute reperfusion therapy were identified. Post thrombolysis brain imaging were reviewed to evaluate for any symptomatic intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysms. RESULTS: A total of 637 patients received IV thrombolysis in our center during a 9.3 years period. 33 (5.1%) were found to have at least one intracranial aneurysm. 24(72.7%) of those received only IV thrombolysis and 9 patients received combination of IV and IA thrombolysis. The size of the largest aneurysm was 9 mm (Range: 2 mm to 9 mm). No symptomatic intracranial hemorrhage occurred among the 24 patients receiving only IV thrombolysis. Out of those who received a combination of IV and IA thrombolysis, 1 developed symptomatic intraparenchymal hemorrhage with intraventricular extension in the location of acute infarct, distant to the aneurysm location. CONCLUSION: Our findings suggest that neither IV thrombolysis nor combination IV and IA thrombolysis increase the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for IV thrombolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.

To date, very few studies focused their attention on efficacy and safety of recanalisation therapy in acute ischemic stroke (AIS) patients with cancer, reporting conflicting results. We retrospectively analysed data from our database of consecutive patients admitted to the Udine University Hospital with AIS that were treated with recanalisation therapy, i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and bridging therapy, from January 2015 to December 2019. We compared 3-month dependency, 3-month mortality, and symptomatic intracranial haemorrhage (SICH) occurrence of patients with active cancer (AC) and remote cancer (RC) with that of patients without cancer (WC) undergoing recanalisation therapy for AIS. Patients were followed up for 3 months. Among the 613 AIS patients included in the study, 79 patients (12.9%) had either AC (n = 46; 7.5%) or RC (n = 33; 5.4%). Although AC patients, when treated with IVT, had a significantly increased risk of 3-month mortality [odds ratio (OR) 6.97, 95% confidence interval (CI) 2.42–20.07, p = 0.001] than WC patients, stroke-related deaths did not differ between AC and WC patients (30% vs. 28.8%, p = 0.939). There were no significant differences between AC and WC patients, when treated with MT ± IVT, regarding 3-month dependency, 3-month mortality and SICH. Functional independence, mortality, and SICH were similar between RC and WC patients. In conclusion, recanalisation therapy might be used in AIS patients with nonmetastatic AC and with RC. Further studies are needed to explore the outcome of AIS patients with metastatic cancer undergoing recanalisation therapy.

Gender disparity in a cohort of stroke patients with incidence of obstructive sleep apnea

Introduction: Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007. Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.

Section Editors: Marc Fisher MD Antoni Davalos MD The Food and Drug Administration (FDA) evaluates applications for new human drugs, biologics, and complex medical devices. Companies must obtain FDA approval to legally market these products. In August, the FDA gave Concentric Medical clearance to market its Merci Retriever system to “remove blood clots from the brain in patients experiencing an ischemic stroke.” Given that the FDA is charged with “protecting the public health by assuring the safety, efficacy, and security of… biological products and medical devices…, ” “advancing public health by helping to speed innovations that make medicines … more effective, safer, and more affordable,” and “helping the public get the accurate, science-based information they need to use medicines … to improve their health,”1 the FDA’s decision to approve the Merci Retriever system is of concern. The pathways to approval are reviewed by Felten et al in the accompanying article and are outlined in Figure 1. Figure 1. Potential pathways for device approval. The decision to approve the Merci Retriever was based on data from the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Trial; the approval was granted through the 510(k) process. The Merci Retriever system includes a flexible nickel titanium (nitinol) wire that obtains a helical shape once it is passed through the tip of the guidance catheter. In practice, the catheter/wire is passed distal to the thrombus, the catheter is removed, and the helical configuration assumed by the wire; the clot is then trapped in the helix and withdrawn from the vasculature (Figure 2). The 510(k) clearance means that the Merci Retriever was felt to be substantially equivalent to a predicate device. In this case, the predicate device was the Concentric Retriever, which itself received 510(k) clearance by the FDA in May 2001 for “use in …

BackgroundPost-stroke depression (PSD) refers to a depressive state that appears after stroke onset and is one of the most common complications in ischemic stroke patients. The occurrence of PSD exacerbates the risk of disability and increases the mortality of patients. Current diagnosis of PSD is severely underdiagnosed.MethodsPatients hospitalized for acute ischemic stroke between December 2019 and November 2022 in the Department of Neurology of Sinopharm Gezhouba Central Hospital were retrospectively collected. Patients’ basic clinical information, test data and related questionnaire scores were collected. They were divided into PSD group and NPSD group. Multivariate regression was used to analyze the risk factors of post-stroke depression and establish a risk prediction model to draw nomograms. Receiver Operating Characteristic Curve (ROC), Calibration curve and Decision Curve Analysis (DCA) decision curve were drawn using R language to assess the clinical efficacy and clinical utility of the model.ResultsPost-stroke depression in Acute Ischemic Stroke (AIS) patients was associated with single factors such as hypertension, living alone, education level, homocysteine level, National Institute of Health Stroke Scale (NIHSS) score, lymphocyte count, neutrophil count (P < 0.05). Among them, living alone, CRP level, hypertension, homocysteine level, education level, systemic immune inflammation index (SII), and NIHSS score were independent risk factors for post-stroke depression in AIS patients (P < 0.05). The seven selected variables were used to construct a risk prediction model, nomograms were drawn, and ROC curves were used to assess model discrimination, AUROC = 0.881. Calibration curve is used to evaluate the consistency of the model, DCA decision curve is used to evaluate the practicability of the model, and this model has good discrimination ability, calibration and clinical practicability.ConclusionThe probability of PSD in AIS patients in this study was 26.51%. Independent risk factors for developing PSD, including CRP level, living alone, history of hypertension, homocysteine level, education level, SII, NIHSS score to establish risk prediction model and draw nomograms. The model was demonstrated to have good discrimination, calibration and clinical utility by internal validation.

Is epicardial fat thickness associated with acute ischemic stroke in patients with atrial fibrillation?

Introduction: Asymptomatic hemorrhagic transformation (AHT) is a common complication in acute ischemic stroke (AIS) patients treated with endovascular therapy. However, whether AHT has impact on the functional outcome of this patient’s populations is unclear, especially in patients treated with endovascular thrombectomy (ET). In this study, we aim to evaluate the influence of AHT on the functional outcome of AIS patients treated with ET. Methods: This observational study based on a prospective registry study. AIS patients with anterior circulation large artery occlusion and underwent ET with second-generation stent retrievers (i.e., Solitaire FR and Trevo) were recruited. AHT was diagnosed by CT according to the Heidelberg Bleeding Clarification. Head CT was performed 12-24 hours and 5-7 days post-treatment. The primary outcome was functional outcome at 3 months post-treatment assessed by modified Rankin Scale (mRS). Results: One hundred and two consecutive AIS patients (aged 61.1 years old) were recruited. 39 patients (38.2%) had AHT on post-treatment CT. Patients with AHT were more likely to receive post-procedures sedation (69.2% vs. 23.8%, p &lt;0.001). Less patients with AHT achieved favorable outcome (mRS&lt;3) at 3 months follow up (35.9% vs. 61.9%, p =0.011). Compared with 7 of 63 subjects (11.1%) died in no AHT group, 14 of 39 subjects (35.9%) died in AHT group, which was significantly higher ( p =0.003). The median length of follow-up was 19 (IQR 3.5-32) months. In long-term follow up, less patients with AHT achieved favorable outcome (30.8% vs. 66.7%, p &lt;0.001). 15 of 26 subjects (57.7%) died in AHT group, as compared with 8 of 50 subjects (16.0%) died in no AHT group, which was significant higher ( p &lt;0.001). On multivariate analysis, AHT was an independent predictor for both short- and long-term functional outcome and mortality. Conclusions: In AIS patients undergoing ET with second-generation stent retrievers, AHT is associated with increased risk of poor outcome.

This study aimed to investigate the association between iron content in grey matter (GM) nuclei and functional outcome in acute ischaemic stroke (AIS) patients utilizing quantitative susceptibility mapping. Forty AIS patients and 40 age-, sex- and education-matched healthy controls underwent quantitative susceptibility mapping to assess susceptibility values, which are positively correlated with iron content, in the caudate nucleus, putamen, globus pallidus, thalamus, red nucleus and substantia nigra. The nuclei on the contralateral side were measured in AIS patients to minimize confounding due to oedema or haemorrhage. Functional outcome was determined by the modified Rankin Scale (mRS) score at 3 months after stroke. Poor outcome was defined as mRS >2, whilst a good outcome was defined as ≤2. Susceptibility values were significantly higher in most contralateral GM nuclei in AIS patients than in the corresponding left or right nuclei in healthy controls. AIS patients with poor outcome showed significantly lower susceptibility value than those with good outcome in the contralateral caudate nucleus, but no significant differences were observed in other GM nuclei. Binary logistic regression analysis revealed a significant association between the susceptibility value of the contralateral caudate nucleus and poor outcome after adjustment for confounders (adjusted odds ratio 0.692, 95% confidence interval 0.486-0.986, p = 0.042). Receiver operating characteristic curve analysis showed an acceptable ability of the susceptibility value of the contralateral caudate nucleus to predict poor outcome (area under the curve 0.740, p = 0.013). Lower iron content in the contralateral caudate nucleus was associated with poor functional outcome in AIS patients.

ObjectiveTirofiban plus recombinant tissue plasminogen activator (rtPA) shows good efficacy and safety in treating acute ischemic stroke (AIS) patients, but there is a lack of comprehensive assessment. This meta-analysis aimed to compare the efficacy and safety of rtPA plus tirofiban with rtPA alone in AIS patients. MethodsThis meta-analysis retrieved studies comparing rtPA intravenous thrombolysis followed by tirofiban (rtPA+T group) versus rtPA intravenous thrombolysis alone (rtPA group) for AIS patients in Excerpt Medica Database, Web of Science, Cochrane, PubMed, China National Knowledge Infrastructure, Wanfang, and SinoMed until March 2024. ResultsTwenty studies with 2048 AIS patients were enrolled in this meta-analysis. National Institute of Health stroke scale (NIHSS) score after treatment was lower in the rtPA+T group than the rtPA group [standardized mean differences (SMD)=-1.41; 95 % confidence interval (CI)=-1.83, -0.98; P<0.001]. The proportion of AIS patients achieving a favorable functional outcome (modified Rankin Scale score ≤2) was increased in the rtPA+T group versus the rtPA group [relative risk (RR)=1.13; 95 % CI=1.05, 1.21; P=0.001]. The incidence of re-occlusion was lower in the rtPA+T group than in the rtPA group (RR=0.24; 95 % CI=0.10, 0.59; P=0.002), but the incidence of intracranial hemorrhage (ICH) (RR=0.85; 95 % CI=0.51, 1.43), symptomatic ICH (RR=1.10; 95 % CI=0.43, 2.84), and mortality (RR=1.39; 95 % CI=0.53, 3.65) was not different between the two groups (all P>0.05). The stability assessed by sensitivity analysis was good, and no publication bias was found. ConclusionrtPA plus tirofiban achieves superior efficacy with comparable safety profiles compared to rtPA alone in AIS patients.