Endovascular thrombectomy with or without intravenous thrombolysis in large-vessel ischemic stroke: an updated meta-analysis

Guidelines continue to recommend intravenous thrombolysis before endovascular thrombectomy for acute ischemic stroke due to large-vessel occlusion. Its added benefit remains debated. This meta-analysis investigated whether bridging therapy with systemic thrombolytics improves functional independence compared with thrombectomy treatment alone. A systematic search of randomized controlled trials comparing intravenous thrombolysis plus endovascular treatment versus endovascular thrombectomy alone was conducted. We searched PubMed, Embase, Web of Science, Cochrane Library, and medRxiv to June 3, 2025. Search terms included “stroke”, “thrombectomy”, and “thrombolysis” and synonyms. The primary efficacy outcome was functional independence at 90 days, defined as a modified Rankin scale (mRS) score of 0 to 2. Random-effects models with inverse-variance weighting were used to calculate pooled risk ratios. Heterogeneity was quantified by Chi-square and I2 statistics. The study was registered in PROSPERO (CRD42022361110). Seven trials (BRIDGE-TNK, DEVT, DIRECT-MT, DIRECT-SAFE, MR CLEAN-NO IV, SKIP, and SWIFT DIRECT), comprising a total of 2,884 patients (1,436 received endovascular thrombectomy alone; 1,448 received intravenous thrombolysis plus thrombectomy), were included. The risk of bias of the included studies was moderate. Functional independence (mRS score of 0 to 2) occurred in 48.1% of patients (n = 690) treated with endovascular thrombectomy alone compared with 51.2% of patients (n = 742) in the intravenous thrombolysis plus endovascular thrombectomy group (risk ratio 0.94, 95% CI, 0.87–1.01). Secondary efficacy and safety outcomes did not differ significantly. The procedure of endovascular thrombectomy alone did not differ significantly from the combination of intravenous thrombolysis plus thrombectomy in terms of functional independence (mRS 0 to 2) at 90 days.