Intravenous Thrombolysis Before Versus Direct Endovascular Treatment for Acute Ischemic Stroke Due to Large Vessel Occlusion: A Systematic Review and Meta-analysis.

OBJECTIVE This study aimed to evaluate the potential efficacy of bridging intravenous thrombolysis (IVT) before endovascular treatment (EVT) in patients with large vessel occlusion (LVO).

METHODS We systematically searched PubMed, ClinicalTrials.gov, Cochrane Library, and Web of Science up to December 1, 2025 to identify randomized controlled trials (RCTs) comparing IVT plus EVT with EVT alone at guideline-recommended doses. The primary outcome was functional independence at 90 days (modified Rankin Scale [mRS] score 0-2). Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model, with subgroup analyses conducted by thrombolytic agent.

RESULTS Six RCTs comprising 2,680 patients were included. Compared to EVT alone, IVT plus EVT may be associated with a higher likelihood of functional independence (RR 1.08, 95% CI 1.00-1.17; P = 0.04). Subgroup analysis showed a significant benefit of functional independence with tenecteplase (RR 1.22, 95% CI 1.03-1.44; P = 0.02), but not with alteplase (RR 1.04, 95% CI 0.96-1.14; P = 0.35). Moreover, IVT plus EVT was associated with a higher likelihood of successful recanalization before EVT (RR, 2.38; 95% CI, 1.38 to 4.12; P = 0.002). The safety outcomes demonstrated that no evidence of a difference was observed between the IVT plus EVT and EVT alone groups.

CONCLUSIONS IVT plus EVT may be associated with higher likelihood of functional independence and early recanalization in LVO patients. However, these findings require confirmation in larger RCTs.