Table 1

Pros and cons of bridging therapy

Potential harmEffectPotential benefitEffect
IV tPA costAdds to procedural cost 
Delay to EVT initiation29Later median onset to reperfusion resulting in worse outcomes
Proximal thrombus migration:43 vertebral to basilar or extracranial ICA to ICA T or M1Neurologic deterioration and more severe/extensive ischemia 
IV tPA associated allergic reactions (1%)44 such as angioedema/hypotension and anaphylactoid reactionDuring IV tPA infusion/EVT procedure which may worsen ischemia or require intubation/prolonged ICU stay 
 Ultra-early reperfusion by first angiography run (5–10%),9 11 21 especially if short thrombi21/residual flow21/occult antegrade flow45High rates of good/excellent clinical outcomes for this subpopulation
Distal thrombus migration:46 47 M1 to distal M2 or beyondEarly neurologic improvement
Softens thrombus for mechanical thrombectomyFewer passes of stent devices22/less cost; shorter procedure time/better outcomes48
IV tPA reperfusion of persisting distal emboli post EVT procedureBetter outcomes since more complete reperfusion (TICI 3)
Higher chance of reperfusion when no EVT access to thrombus (recanalization at 2–8 h: 37% IV tPA vs 7% no IV tPA9)Higher proportion with early reperfusion translating to better outcomes
Tandem extracranial and intracranial occlusions may require stenting during EVT and immediate antiplatelet therapyMore symptomatic intracranial hemorrhage (10%)49 
IV tPA-related blood brain barrier breakdown50 and coagulopathy51More symptomatic parenchymal hemorrhage within infarct 
IV tPA-related coagulopathy51 and small vessel fragility52More large symptomatic extra-ischemic parenchymal hemorrhage (1–2%)52 
IV tPA-related coagulopathy51Puncture site hematoma (1–2%)9 
IV tPA-related coagulopathy51Major systemic bleeding (1%)44 
IV tPA lysis of left atrial appendage53 or other proximal thrombusEarly stroke recurrence54 or multiple systemic emboli55 
IV tPA-related neurotoxicity in animal models56More neuronal loss 
  • EVT, endovascular therapy; ICA, internal carotid artery; IV, intravenous; tPA, tissue plasminogen activator.