Background and Purpose: Posterior circulation stroke (PCS) accounts for 8-12% of acute stroke patients receiving intravenous thrombolysis (IVT). We aimed to compare safety and outcomes following IVT between patients with PCS and anterior circulation stroke (ACS), and incorporate the results in a meta-analysis. Methods: We included patients in the SITS Thrombolysis Registry 2013–2017 with CT/MR angiographic occlusion data. Outcomes were parenchymal hematoma (PH), symptomatic ICH (SICH) per SITS-MOST, ECASS-II and NINDS, 3-month modified Rankin Scale score, and death. Matching for SICH risk factors (age, sex, NIHSS, blood pressure, glucose, atrial fibrillation) was done using inverse probability weighting. Meta-analysis of studies comparing outcomes in PCS vs ACS after IVT was conducted. Results: Of 5146 patients, 753 had PCS (14.6%). PCS patients had lower median NIHSS: 7 (IQR 4-13) vs 13 (7-18), p<0.001, and less frequent cerebrovascular risk factors. PH occurred in 3.2% PCS patients versus 7.9% in ACS. After matching, bleeding complications and mortality were lower in PCS vs ACS (95% CI for group difference): PH 3.1% vs 7.7% (3.0%-6.3%); SICH SITS-MOST 0.5% vs 1.9% (0.8%-2.2%) 3-month death (70% data availability) 12.8% vs 19.3% (1.1%-12.1%). Differences in rates of SICH NINDS, SICH ECASS-II and 3-month mRS 0-2 were non-significant. Meta-analysis including 13 studies showed relative risk for SICH in PCS versus ACS being 0.49, (95% CI 0.32-0.75). Conclusions: Posterior circulation stroke carries approximately half the risk of bleeding complications after IVT compared to ACS and has similar functional outcomes, acknowledging limitations of the NIHSS for stroke severity or infarct size adjustment.
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