Bridging Thrombolysis Versus Direct Endovascular Thrombectomy in Acute Ischemic Stroke Patients With ASPECTS ≤5: A...

Endovascular thrombectomy (EVT) is a standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, the efficacy and safety of bridging thrombolysis (BT) compared to direct EVT (dEVT) remain controversial, particularly in patients with large core infarcts (Alberta stroke program early CT score [ASPECTS] ≤5). This meta-analysis aimed to compare the efficacy and safety of BT versus dEVT in this population.

We systematically searched PubMed, Embase, and Web of Science from January 1, 2010, to September 21, 2024, for studies comparing BT and dEVT in AIS patients with ASPECTS ≤5. Outcomes included functional outcomes (mRS 0-2 and 0-3), intracranial hemorrhage (ICH), symptomatic ICH (sICH), 90-day mortality, and successful reperfusion. Data were pooled using random-effects models.

Twelve studies (3907 patients) were included. BT significantly improved favorable (OR: 1.43, 95% CI: 1.17-1.76) and moderate functional outcomes (OR: 1.28, 95% CI: 1.10-1.48) compared to dEVT. No significant differences were observed in sICH, ICH, 90-day mortality, or successful reperfusion.

Our findings suggest that BT may be associated with better functional outcomes in patients with ASPECTS ≤5, without increasing major safety events compared with dEVT. However, these findings should be interpreted cautiously because the evidence is mainly observational, and residual confounding cannot be excluded. Further well-designed randomized controlled trials are needed to confirm these findings.