# 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.

## Key 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.