Objective:

To compare technical efficacy and safety of intravenous thrombolysis prior to mechanical
thrombectomy versus direct thrombectomy in acute ischemic stroke

Background:

Bridging thrombolysis is widely practised with thrombectomy, yet published data show mixed
conclusions on functional benefit, reperfusion quality, and hemorrhagic risk, emphasizing the
need for an updated synthesis of technical and safety outcomes.

Design/Methods:

A Systematic review and meta-analysis was conducted according to PRISMA guidelines.
Suitable studies were identified through major databases until September 2025. Pooled odds
ratio (ORs) was calculated using fixed effects models.

Results:

Across 9 included RCTs, mortality was similar between the two strategies (16.84% with
bridging vs 17.34% with direct thrombectomy; OR 0.97, 95% CI 0.80-1.17; I²=0), indicating
no higher risk with bridging thrombolysis. Early technical efficacy favored bridging, with
higher first‑run successful reperfusion (5.16% vs 1.50%; OR 3.62, 95% CI 1.89-6.93; I²=0)
and higher final angiographic success by eTICI 2b/2c/3 (81.78% vs 78.35%; OR 1.26, 95%
CI 1.03-1.53; I²=0) . Recanalization at 24–72 hours was higher with bridging (87.13% vs
83.48%; OR 1.33, 95% CI 0.98-1.82; I²=0) . Symptomatic intracranial hemorrhage was
numerically higher with bridging but not statistically significant (6.22% vs 4.92%; OR 1.28,
95% CI 0.93-1.77; I²=0) . Embolization to a new territory (11.05% vs 11.96%; OR 0.90) and
new‑territory infarction at 5-7 days (6.52% vs 7.93%; OR 0.82) were similar between the
groups.

Conclusions:

Bridging thrombolysis before thrombectomy improved early and final angiographic
reperfusion without increasing mortality or definitively raising hemorrhage risk, supporting
continued use in eligible patients. Further large scale studies are needed to refine
optimization for individualized benefits.