Repeat thrombolysis within 90 days: no symptomatic bleeds in 63 published cases, but safety is unproven

Design

Systematic review and individual-patient data meta-analysis of case reports and series

Population

63 patients (individual data for 44) with repeat thrombolysis within 90 days

Primary outcome

Functional outcome and symptomatic intracranial haemorrhage

Effect

Favourable outcome 66.7%; no symptomatic ICH; pooled OR 1.52 (0.97-2.39)

Guidelines and product labels list ischaemic stroke in the previous three months as a contraindication or potential harm for intravenous thrombolysis; the authors call it a relative contraindication resting largely on expert opinion. This systematic review gathered every published case of repeat thrombolysis within 90 days of an earlier thrombolysed stroke: 28 reports, 63 patients, with individual data for 44.

The median interval between treatments was 7.5 days. Two-thirds (66.7%) had a favourable outcome. There was no symptomatic intracranial haemorrhage; asymptomatic intracranial or systemic haemorrhage occurred in 15.9%, and 5% died of causes the authors judged unrelated to neurological complications. Bleeding and death clustered in cardioembolic and more severe strokes.

These are published case reports and series, which favour good outcomes. The data cannot establish safety. The authors suggest the interval alone need not rule a patient out, but guidelines and labels differ, and any decision needs stroke-specialist input.

• Published case reports suggest a thrombolysed stroke within 90 days need not, by itself, rule a patient out, but guidelines and product labels differ; decide with stroke-specialist input.
• Be more cautious with cardioembolic and severe strokes, where bleeding and deaths concentrated.
• Check imaging for haemorrhagic transformation or a large established infarct from the first stroke.
• Record and report cases of repeat thrombolysis; the evidence base is still tiny.

Why it matters

It gathers the published cases on the 90-day window, where guidance rests largely on consensus; case reports cannot overturn that guidance.

Don't overread it

Published case reports favour good outcomes; this cannot show that repeat thrombolysis is safe.

The statistics, in plain English

An odds ratio of 1.52 with an interval from 0.97 to 2.39 includes no effect, so the apparent benefit is not established. With 63 patients drawn from published reports, cases that went badly are likely to be under-represented.

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