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.