Tandem lesions, involving simultaneous extracranial and intracranial occlusions, present therapeutic challenges in acute ischemic stroke. The benefit of bridging therapy (IVT+EVT) over EVT alone remains debated.

A systematic review and meta-analysis of PubMed-indexed studies was performed. Binary outcomes were pooled using the Mantel–Haenszel method under a random-effects model (DerSimonian–Laird). Effect sizes were expressed as odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed with I² and Cochran’s Q. Publication bias was evaluated using Egger’s and Begg’s tests, and trim-and-fill analysis.

Twenty-one studies were included. For functional independence (90-day mRS 0–2), IVT+EVT significantly improved outcomes compared to EVT alone (fixed-effect OR 1.35; 95% CI 1.16–1.57; I²=7.1%; random-effects OR 1.34; 95% CI 1.13–1.59). For successful reperfusion (mTICI 2b–3), IVT+EVT also showed benefit (fixed-effect OR 1.50; 95% CI 1.19–1.89; I²=6.9%; random-effects OR 1.48; 95% CI 1.15–1.91). For symptomatic intracranial hemorrhage, no significant difference was observed between IVT+EVT and EVT alone (fixed-effect OR 0.97; 95% CI 0.71–1.33; random-effects OR 0.97; 95% CI 0.71–1.33; I²=0%). Prediction intervals confirmed robustness, and heterogeneity was low across all analyses. Publication bias was minimal, though trim-and-fill suggested up to 3 potentially missing studies for some outcomes.

Bridging therapy with IVT+EVT improves functional independence and reperfusion success without increasing hemorrhagic risk in tandem occlusions. These findings support IVT administration prior to EVT when not contraindicated.