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Bridging thrombolysis improves survival rates at 90 days compared with direct mechanical thrombectomy alone in acute ischemic stroke due to basilar artery occlusion: a systematic review and meta-analysis of 1096 patients
  1. Keng Siang Lee1,
  2. Isabel Siow2,
  3. John JY Zhang3,
  4. Nicholas L Syn2,
  5. Conor S Gillespie4,
  6. Linus ZH Yuen2,
  7. Gopinathan Anil2,5,
  8. Cunli Yang2,5,
  9. Bernard PL Chan2,6,
  10. Vijay Kumar Sharma2,6,
  11. Hock-Luen Teoh2,6,
  12. Jing Mingxue2,6,
  13. Kevin Soon Hwee Teo6,
  14. May Zin Myint2,6,
  15. Pervinder Bhogal7,
  16. Lukas Meyer8,
  17. Stefan Schob9,
  18. Ching-Hui Sia2,10,
  19. Anastasios Mpotsaris11,
  20. Volker Maus11,
  21. Tommy Andersson12,13,
  22. Fabian Arnberg12,
  23. Vamsi Krishna Gontu12,
  24. Tsong-Hai Lee14,
  25. Benjamin Y Q Tan2,6,
  26. Leonard LL Yeo2,6
  1. 1 Bristol Medical School, University of Bristol, Bristol, UK
  2. 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  3. 3 Department of Neurosurgery, National Neuroscience Institute, Singapore
  4. 4 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
  5. 5 Divison of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore
  6. 6 Division of Neurology, Department of Medicine, National University Health System, Singapore
  7. 7 Department of Interventional Neuroradiology, St. Bartholomew’s and The Royal London Hospital, London, UK
  8. 8 Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  9. 9 Department of Neuroradiology, Clinic and Policlinic of Radiology, University Hospital Halle/Saale, Halle, Germany
  10. 10 Department of Cardiology, National University Heart Centre Singapore, Singapore
  11. 11 Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
  12. 12 Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
  13. 13 Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
  14. 14 Department of Neruology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
  1. Correspondence to Dr Keng Siang Lee, Bristol Medical School, University of Bristol, Bristol, United Kingdom; mrkengsianglee{at}


Background Mechanical thrombectomy (MT) is an effective treatment for patients with acute ischemic stroke (AIS) from basilar artery occlusion (BAO).

Objective To compare the clinical outcomes of MT, with and without bridging intravenous thrombolysis (IVT), in acute BAO through a systematic review and meta-analysis of the current literature.

Methods Systematic searches of Medline, EMBASE, and Cochrane Central were undertaken on August 1, 2022. Good functional outcome defined as 90-day modified Rankin Scale score 0–2 was the primary outcome measure. Secondary outcome measures were 90-day mortality, successful post-thrombectomy recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and subarachnoid hemorrhage (SAH).

Results Three studies reporting 1096 patients with BAO AIS were included in the meta-analysis. No significant differences in good functional outcome were detected between the two groups (RR=1.28 (95% CI 0.86 to 1.92); p=0.117). However, specifically patients with large artery atherosclerosis (LAA) benefited from bridging IVT (OR=2.52 (95% CI 1.51 to 4.22); p<0.001) with better functional outcomes. There was a significantly lower 90-day mortality rate for patients who underwent bridging IVT compared with MT alone (RR=0.70 (95% CI 0.62 to 0.80); p=0.008). No significant differences were detected in rates of post-treatment recanalization (RR=1.01 (95% CI 0.35 to 2.91); p=0.954), sICH (RR=0.96 (95% CI 0.66 to 1.42); p=0.724), and SAH (RR=0.93 (95% CI 0.31 to 2.83); p=0.563).

Conclusions In patients with AIS due to BAO, bridging IVT was associated with lower mortality rates at 90 days, compared with direct MT. There were no improved functional outcomes or increased sICH or SAH between both arms, However, patients with LAA benefited from bridging IVT, with better functional outcomes.

  • Thrombectomy
  • Thrombolysis
  • Artery
  • Stroke
  • Complication

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors KSL: conceptualization, methodology, investigation, acquisition of data, data analysis, software, writing – original draft, writing – review & editing, visualization, approval of manuscript, guarantor of the study. IS: acquisition of data, writing – review and editing, approval of manuscript. JJYZ, NLS, CSG, LZHY, GA, CY, BPLC, VKS, H-LT, JM, KSHT, MZM, PB, LM, SS, C-HS, AM, VM, TA, FA, VKG, T-HL: writing – review and editing, approval of manuscript. BYQT: methodology, writing – review and editing, approval of manuscript. LLLY: conceptualization, methodology, writing – review and editing, approval of manuscript, guarantor of the study.

  • Funding This research was sponsored by the National Medical Research Council (NMRC), Singapore. NMRC/MOH-TA19Nov-0003.

  • Competing interests GA: Stryker Neurovascular, Penumbra Inc, Medtronic: payments were received by the employer for consulting and proctoring assignments.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.