To Bridge or Not to Bridge? A Meta-Analysis of Intravenous Thrombolysis Before Thrombectomy in Large Ischemic Core...

Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, the role of preceding intravenous thrombolysis (IVT) in patients with sizable ischemic core infarcts remains unclear. This systematic review and meta-analysis aimed to compare the clinical efficacy and safety of bridging therapy (IVT followed by EVT) versus EVT alone in this specific high-risk subgroup.

Following PRISMA guidelines, a comprehensive literature search was conducted across PubMed, Web of Science, and Scopus to identify studies comparing bridging therapy (IVT + EVT) with EVT alone in patients with large ischemic cores. Primary efficacy outcomes included favorable functional status, defined as modified Rankin Scale (mRS) scores of 0-1 and 0-2 at follow-up. Primary safety outcomes were rates of symptomatic intracranial hemorrhage (sICH) and any intracranial hemorrhage (ICH). Secondary outcomes assessed successful reperfusion and mortality. Data were pooled using random-effects models and reported as risk ratios (RR) with 95% confidence intervals (CI).

Seven cohort studies met the inclusion criteria. No significant differences were observed between the two treatment strategies in achieving mRS 0-1 (RR = 0.78; 95% CI: 0.52-1.19; p = 0.25) or mRS 0-2 (RR = 0.70; 95% CI: 0.46-1.08; p = 0.11). Similarly, rates of sICH (RR = 0.93; 95% CI: 0.67-1.28; p = 0.64), any ICH (RR = 0.90; 95% CI: 0.79-1.04; p = 0.15), successful recanalization (RR = 0.92; 95% CI: 0.83-1.03; p = 0.14), and mortality (RR = 1.08; 95% CI: 0.96-1.21; p = 0.20) were comparable between groups.

In patients with large ischemic core infarcts, administering IVT prior to EVT does not confer significant clinical or procedural advantages over EVT alone. These findings underscore the need for further randomized controlled trials to inform optimal treatment approaches for this challenging patient population.