Direct thrombectomy versus bridging alteplase medicine in anterior circulation stroke following endovascular therapy: a multi-center cohort study.

OBJECTIVE: Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and endovascular therapy (EVT) are established treatments for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation. This study aimed to compare the safety and efficacy of bridging therapy (rt-PA before EVT) versus direct EVT in a real-world, multicenter setting. METHODS: In this retrospective multicenter cohort study, 724 patients with anterior circulation AIS treated with EVT within 8 h of symptom onset were analyzed. Patients received either pre-EVT rt-PA (n = 314) or direct EVT without rt-PA (n = 410). Primary outcomes included 3-month functional independence (modified Rankin Scale (mRS) 0-2), excellent outcome (mRS 0-1), and mortality. Secondary outcomes included hemorrhagic transformation, parenchymal hematoma, and successful reperfusion (mTICI ≥ 2b). Multivariate logistic regression was adjusted for key clinical confounders. RESULTS: Baseline characteristics were comparable, except for higher median NIHSS scores in the direct EVT group (16 vs. 15, p < 0.001). No significant differences were observed in 3-month functional independence (43.0% vs. 50.3%, p = 0.051), excellent outcome (36.8% vs. 42.0%, p = 0.155), or mortality (22.9% vs. 20.1%, p = 0.354). Hemorrhagic transformation and parenchymal hematoma rates were similar. Although successful reperfusion was higher in the rt-PA group (93.6% vs. 88.5%, p = 0.019), this did not remain significant after adjustment. CONCLUSION: Pre-EVT rt-PA did not improve functional outcomes or reduce mortality in AIS patients. While rt-PA showed a trend toward higher reperfusion rates, this did not translate to clinical benefit. Hemorrhage risks were similar between groups.