Article Text

Download PDFPDF
Clinical evidence comparing bridging and direct endovascular thrombectomy: progress and controversies
  1. Xuesong Bai1,2,
  2. Zhaolin Fu1,2,
  3. Xue Wang3,
  4. Chengyu Song4,
  5. Xin Xu1,2,
  6. Long Li1,2,
  7. Yao Feng1,2,
  8. Adam A Dmytriw5,6,
  9. Robert W Regenhardt6,
  10. Ziyi Sun1,2,
  11. Bin Yang1,2,
  12. Liqun Jiao1,2,7
  1. 1 Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
  2. 2 China International Neuroscience Institute, Beijing, China
  3. 3 Library Department, Xuanwu Hospital, Capital Medical University, Beijing, China
  4. 4 Library Department, Beijing Luhe Hospital, Capital Medical University, Beijing, China
  5. 5 Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
  6. 6 Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  7. 7 Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
  1. Correspondence to Dr Liqun Jiao, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; liqunjiao{at}; Dr Bin Yang; yangbin_81{at}


Clinical evidence comparing bridging endovascular thrombectomy (bEVT) with intravenous thrombolysis and direct endovascular thrombectomy (dEVT) without thrombolysis for patients with acute ischemic stroke (AIS) presented directly to an EVT-capable center is overwhelming but inconsistent. This study aimed to analyze the progress and controversies in clinical evidence based on current meta-analyses. Three databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched. Relevant data were extracted and reviewed from the pooled studies. The Assessment of Multiple Systematic Review (AMSTAR-2) was used for quality assessment. Twenty-five meta-analyses were finally included. There were 56% (14/25) from Asian countries, 20% (5/25) from North America, and 24% (6/25) from Europe. The majority (72%, 18/25) of evidence arose in a short period from 2020 to 2022 with the serial publication of four randomized controlled trials (RCTs). Among the 25 meta-analyses, 11 pooled at least three RCTs but there is substantial overlap among seven (five recruited the same four RCTs solely and two recruited the same three RCTs solely). Meanwhile, quality rating based on AMSTAR-2 showed 16 ‘high’ rated studies (64%). For functional independence, 40% (10/25) of studies favored bEVT and 60% showed neutral results. For symptomatic intracerebral hemorrhage, most studies (82.6%, 19/23) showed no significant difference. Non-RCT studies contributed to evidence favoring bEVT. Current RCTs provide an update of clinical evidence comparing bEVT and dEVT. However, they simultaneously contribute to an unnecessary overlap among studies. Contemporary observational studies demonstrated different but possibly confounded evidence. Thus, this issue still requires more clinical evidence under standard procedures.

  • stroke
  • thrombectomy
  • thrombolysis

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • XB, ZF and XW are joint first authors.

  • Twitter @XuesongBai7, @AdamDmytriw

  • BY and LJ contributed equally.

  • XB, ZF and XW contributed equally.

  • Contributors BY, LJ, XB, and ZF contributed to the initial idea for this study. XB, ZF, XW, CS, XX, LL, and YF finished the study design. BY and LJ were consulted about the clinical issues. XB, ZF, and XW contributed to the original draft. BY, LJ, AAD, RWR, XB, ZF, and ZS were responsible for the revision of the draft. XB, ZF, and XW contributed equally to this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction, or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • 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.