Efficacy and safety of treatment strategies for early neurological deterioration after acute ischemic stroke: a network meta-analysis of randomized controlled trials.

BACKGROUND

Early neurological deterioration (END) is a serious complication of acute ischemic stroke and may occur spontaneously or after reperfusion therapy.

OBJECTIVE

To compare the efficacy and safety of different interventions for acute ischemic stroke patients with END using network meta-analysis.

METHODS

Randomized controlled trials were identified through systematic searches of major databases up to February 2026. The primary outcome was the 90-day modified Rankin Scale score. Secondary outcomes included neurological improvement (assessed by NIHSS), intracranial hemorrhage, and mortality.

RESULTS

Five randomized controlled trials including 1,164 patients were analyzed. Compared with standard antiplatelet therapy (ST; which included aspirin monotherapy, placebo plus aspirin, or dual antiplatelet therapy depending on the study protocol), indobufen combined with ST, and tirofiban combined with ST, significantly improved 90-day functional outcome, whereas argatroban combined with standard treatment reduced mean mRS scores but did not significantly increase the proportion of patients achieving favorable functional outcomes (mRS 0-2) or excellent functional outcomes (mRS 0-1). Indobufen demonstrated the highest probability of being the optimal treatment for reducing the mean 90-day mRS score and improving 90-day NIHSS scores based on SUCRA rankings. Indobufen and tirofiban (each added to ST) also significantly improved neurological recovery at short- and long-term follow-up. However, argatroban and tirofiban did not significantly increase the proportion of patients achieving favorable functional outcomes. None of the interventions increased the risk of intracranial or symptomatic hemorrhage.

CONCLUSIONS

Indobufen was associated with lower mean 90-day mRS and NIHSS scores, whereas tirofiban added to standard antiplatelet therapy increased the proportion of patients achieving a favorable functional outcome defined as mRS 0-2. Neither tirofiban nor argatroban significantly increased the proportion achieving an excellent functional outcome defined as mRS 0-1. These findings should be interpreted cautiously because of the limited number and size of the included trials.