Efficacy and safety of bridging intravenous thrombolysis before mechanical thrombectomy in acute ischemic stroke: A systematic review and meta-analysis

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Abstract
Background: The safety and efficacy of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) in acute ischemic stroke remain uncertain. Methods: We comprehensively searched PubMed, Embase, and the Cochrane Library from inception to May 30, 2025. Randomized controlled trials comparing IVT before MT versus MT alone in acute ischemic stroke were included. The primary outcome was excellent functional outcome (modified Rankin Scale score 0–1 at 90 days) and good functional outcome (modified Rankin Scale score 0–2). Secondary outcomes included successful recanalization, all-cause death, symptomatic, and any intracranial hemorrhage. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Results: Seven randomized controlled trials encompassing 2884 patients (MT + IVT: 1448; MT–IVT: 1436) met the inclusion criteria. The pooled analysis demonstrated comparable results for excellent functional outcome (31.3% vs. 29.5%; OR, 1.08 [95% CI, 0.92–1.28]), good functional outcome (51.2% vs. 48.0%; OR, 1.13 [95% CI, 0.96–1.34]) between the MT + IVT and MT alone groups, respectively. Rates of successful recanalization (OR, 1.24 [95% CI, 0.95–1.62]), all-cause death (OR, 0.98 [95% CI, 0.80–1.19]), symptomatic intracranial hemorrhage (OR, 1.21 [95% CI, 0.87–1.68]), and any intracranial hemorrhage (OR, 1.17 [95% CI, 0.97–1.41]) were also comparable between the two groups. Trial sequential analysis demonstrated insufficient evidence to confirm a 20% relative benefit of bridging therapy compared to MT alone. Conclusion: In this study-level meta-analysis, IVT followed by endovascular treatment showed comparable safety and efficacy to endovascular treatment alone, with similar outcomes in functional recovery, successful recanalization, all-cause mortality, symptomatic intracranial hemorrhage, and any intracranial hemorrhage.

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