Bridging IV Thrombolysis Plus EVT vs EVT Alone in Late-Window Anterior Circulation Stroke

This retrospective analysis of a prospective endovascular thrombectomy registry included 772 patients with acute ischemic stroke due to anterior circulation large vessel occlusion treated within the 6- to 24-hour time window across 10 comprehensive stroke centers in China and Singapore. The study compared bridging intravenous thrombolysis plus endovascular thrombectomy with direct endovascular thrombectomy alone. The primary outcome was 3-month favorable functional outcome (modified Rankin Scale 0–2). Secondary outcomes included successful recanalization (mTICI 2b–3), symptomatic intracranial hemorrhage, hemorrhagic transformation, and 3-month mortality.

At 3 months, favorable functional outcome occurred in 44.55% of patients who received bridging intravenous thrombolysis versus 47.03% who received direct endovascular thrombectomy (common OR 0.91; 95% CI 0.56–1.46). Successful recanalization was achieved in 91.09% versus 90.10% (OR 1.11; 95% CI 0.51–2.44). Symptomatic intracranial hemorrhage occurred in 5.94% versus 9.41% (OR 0.61; 95% CI 0.24–1.58). Hemorrhagic transformation occurred in 23.76% versus 23.27% (OR 1.03; 95% CI 0.57–1.85). Three-month mortality was 15.84% versus 13.37% (OR 1.22; 95% CI 0.62–2.37). None of these comparisons reached statistical significance.

Safety events included symptomatic intracranial hemorrhage and hemorrhagic transformation. The study did not report discontinuations or overall tolerability. Key limitations include the observational, nonrandomized design, potential selection bias, and unmeasured confounding. Generalizability may be limited to comprehensive stroke centers with established endovascular programs in China and Singapore. Given these constraints, causal inferences are not warranted.

Clinically, these data suggest that in selected patients with large vessel occlusion presenting within 6 to 24 hours, bridging intravenous thrombolysis may not substantially improve functional outcomes compared with direct endovascular thrombectomy. However, treatment decisions should remain individualized, considering patient eligibility, time to presentation, and institutional protocols. Further randomized evidence is needed to clarify the role of bridging therapy in this late-window population.