Bridging therapy versus direct mechanical thrombectomy in acute ischemic stroke: an updated meta-analysis of real-world evidence

TL;DR

This study finds that bridging therapy improves recovery and reduces death in stroke patients compared to direct mechanical thrombectomy, based on real-world data.

Contribution

An updated meta-analysis of real-world evidence comparing bridging therapy and direct mechanical thrombectomy for acute ischemic stroke.

Findings

Bridging therapy was linked to better recovery and lower mortality in stroke patients.

No significant difference in intracranial hemorrhage rates between the two treatments.

Baseline scores and workflow intervals influenced outcome variability.

Abstract

While randomized controlled trials (RCTs) have compared bridging therapy (BT: IV thrombolysis prior to mechanical thrombectomy) with direct mechanical thrombectomy (dMT) in patients with acute ischemic stroke (AIS), their findings are inconsistent and may not fully represent real-world clinical practice. This study provides an updated synthesis of real-world observational data comparing the safety and efficacy of BT versus dMT in AIS due to large vessel occlusion (LVO). A systematic literature search was conducted across four major databases. Non-randomized studies comparing BT with dMT in AIS patients were included. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models for key clinical outcomes. Risk of bias was assessed using the Newcastle–Ottawa Scale, and publication bias was evaluated through funnel plot symmetry and Egger’s test. Thirty-one observational studies involving 93,297 patients (41,393 BT; 47,960 dMT) were included. BT was associated with significantly higher odds of excellent [modified Rankin Scale (mRS) 0–1; OR = 1.51, 95%CI: 1.30–1.77] and favorable (mRS 0–2; OR = 1.44, 95% CI: 1.29–1.61) recovery at 90 days, greater rates of successful reperfusion (TICI 2b/3; OR = 1.23, 95%CI: 1.09–1.39), and lower 90-day mortality (OR = 0.61, 95% CI: 0.52–0.71) compared with dMT. No significant differences were found in rates of symptomatic intracranial hemorrhage. Sensitivity analyses and publication bias assessments supported the robustness of these findings. Meta-regression identified baseline ASPECTS, NIHSS score, and several workflow intervals as significant predictors of outcome variability. These results support BT’s continued relevance in routine AIS care.

PROSPERO no: CRD420251119894.

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