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

Abdelrahman Elgharabawi, Mostafa Hossam El Din Moawad, Reham M Wagih, Yousr Ahmed, Mohammed Elkholy, Ibrahim Serag, Ibraheem M Alkhawaldeh, Mahmoud Elsayed, Abdelrahman Elkholy, Ahmed Abdelraouf, Obai Yousef, Younes Nabgouri, Mohamed Abouzid

Journal: Brain and behavior 2025;15(11):e71052

PMID: 41273030

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Abstract

BACKGROUND

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.

METHODS

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).

RESULTS

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.

CONCLUSION

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.

Address: Faculty of Biology, Medicine and Health, Manchester University, Manchester, The United Kingdom.; Alexandria Main University Hospital, Alexandria, Egypt.; Faculty of Medicine, Suez Canal University, Ismailia, Egypt.; Department of Total Parenteral Nutrition, Alexandria Main University Hospital, Alexandria, Egypt.; Department of Pulmonology and Critical Care, Johns Hopkins University, Baltimore, Maryland, USA.; The Laboratory for Minimally Invasive Tumor Therapies, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA.; Faculty of Medicine, Mansoura University, Mansoura, Egypt.; Faculty of Medicine, Mutah University, Al-Karak, Jordan.; Stroke and Neurovascular Regulation Laboratory, Charlestown, Massachusetts, USA.; Faculty of Medicine, Alexandria University, Alexandria, Egypt.; Faculty of Medicine, Al-Azhar University, Cairo, Egypt.; Department of Neurosurgery, Tishreen University Hospital, Latakia, Syria.; Department of Internal Medicine First Pavlov State Medical University, Saint Petersburg, Russia.; Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Poznan, Poland.; Doctoral School, Poznan University of Medical Sciences, Poznan, Poland.

DOI: 10.1002/brb3.71052

MeSH Terms: Humans, Thrombectomy, Ischemic Stroke, Thrombolytic Therapy, Treatment Outcome, Endovascular Procedures, Brain Ischemia, Fibrinolytic Agents