{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T05:02:16Z","timestamp":1791522136449,"version":"4.3.4"},"reference-count":29,"publisher":"SAGE Publications","issue":"6","license":[{"start":{"date-parts":[[2021,6,2]],"date-time":"2021-06-02T00:00:00Z","timestamp":1622592000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["International Journal of Stroke"],"published-print":{"date-parts":[[2021,8]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Direct mechanical thrombectomy may result in similar outcomes compared to a bridging approach with intravenous thrombolysis (IVT\u2009+\u2009MT) in acute ischemic stroke. Recent randomized controlled trials have varied in their design and noninferiority margin.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>We sought to meta-analyze accumulated trial data to assess the difference and non-inferiority in clinical and procedural outcomes between direct mechanical thrombectomy and bridging therapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary of review<\/jats:title>\n                    <jats:p>\n                      We conducted a systematic review of electronic databases following the preferred reporting items for systematic reviews and meta-analyses guidelines. Random effects meta-analyses were conducted for the pooled data. The primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS)\u2009\u2264\u20092). Secondary outcomes included excellent functional outcome (mRS\u2009\u2264\u20091), mortality, any intracranial hemorrhage, symptomatic intracranial hemorrhage, successful reperfusion (thrombolysis in cerebral infarction\u2009\u2265\u20092\u2009b), and procedure-related complications. Four randomized controlled trials comprising 1633 patients (817 direct mechanical thrombectomy, 816 bridging therapy) were included. There were no statistical differences for the 90-day good functional outcome (OR\u2009=\u20091.02, 95% CI 0.84\u20131.25, p\u2009=\u20090.54, I\n                      <jats:sup>2\u2009<\/jats:sup>\n                      =\u20090%), and the absolute risk difference was 1% (95% CI: \u22124% to 5%). The lower 95% CI falls within the strictest noninferiority margin of \u221210% among included randomized control trials. Direct mechanical thrombectomy reduced the odds of successful reperfusion (OR\u2009=\u20090.76, 95% CI: 0.60\u20130.97, p\u2009=\u20090.03, I\n                      <jats:sup>2\u2009<\/jats:sup>\n                      =\u20090%) and any intracranial hemorrhage (OR\u2009=\u20090.65, 95% CI: 0.49\u20130.86, p\u2009=\u20090.003, I\n                      <jats:sup>2\u2009<\/jats:sup>\n                      =\u200938%). There was no difference in the remaining secondary outcomes. The risk of bias for all studies was low.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The combined trial data assessing direct mechanical thrombectomy versus bridging therapy showed no difference in improving good functional outcome. The wide noninferiority thresholds set by individual trials are in contrast with the clinical consensus on minimally important differences. However, our pooled analysis indicates noninferiority of direct mechanical thrombectomy with a 4% margin of confidence. The application of these findings is limited to patients presenting directly to mechanical thrombectomy-capable centers and real-world workflow times may differ against those achieved in a trial setting.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/17474930211021353","type":"journal-article","created":{"date-parts":[[2021,5,18]],"date-time":"2021-05-18T12:03:52Z","timestamp":1621339432000},"page":"621-631","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":57,"title":["Direct mechanical thrombectomy without intravenous thrombolysis versus bridging therapy for acute ischemic stroke: A meta-analysis of randomized controlled trials"],"prefix":"10.1177","volume":"16","author":[{"given":"Anna","family":"Podlasek","sequence":"first","affiliation":[{"name":"NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK"},{"name":"Neuroscience and Vascular Simulation, Anglia Ruskin University, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4353-4515","authenticated-orcid":false,"given":"Permesh Singh","family":"Dhillon","sequence":"additional","affiliation":[{"name":"NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK"},{"name":"Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Waleed","family":"Butt","sequence":"additional","affiliation":[{"name":"Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iris Q","family":"Grunwald","sequence":"additional","affiliation":[{"name":"Neuroscience and Vascular Simulation, Anglia Ruskin University, Cambridge, UK"},{"name":"Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5330-8584","authenticated-orcid":false,"given":"Timothy J","family":"England","sequence":"additional","affiliation":[{"name":"Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, UK"},{"name":"Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2021,6,2]]},"reference":[{"key":"bibr1-17474930211021353","doi-asserted-by":"crossref","unstructured":"Turc G, Bhogal P, Fischer U, et\u00a0al. European Stroke Organisation (ESO) \u2013 European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on mechanical thrombectomy in acute ischemic stroke.\n                      J NeuroInterv Surg\n                      . Epub ahead of print 2019. DOI: 10.1136\/neurintsurg-2018-014569.","DOI":"10.1136\/neurintsurg-2018-014568"},{"key":"bibr2-17474930211021353","doi-asserted-by":"crossref","unstructured":"Powers WJ, Rabinstein AA, Ackerson T, et\u00a0al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association\/American Stroke Association.\n                      Stroke\n                      . Epub ahead of print 2018. DOI: 10.1161\/STR.0000000000000158.","DOI":"10.1161\/STROKEAHA.119.026917"},{"key":"bibr3-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.019261"},{"key":"bibr4-17474930211021353","doi-asserted-by":"crossref","unstructured":"Kaesmacher XJ, Boeckh-Behrens T, Simon S, et\u00a0al. Risk of thrombus fragmentation during endovascular stroke treatment.\n                      Am J Neuroradiol\n                      . Epub ahead of print 2017. DOI: 10.3174\/ajnr.A5105.","DOI":"10.3174\/ajnr.A5105"},{"key":"bibr5-17474930211021353","doi-asserted-by":"crossref","unstructured":"Emberson J, Lees KR, Lyden P, et\u00a0al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.\n                      Lancet\n                      . Epub ahead of print 2014. DOI: 10.1016\/S0140-6736(14)60584-5.","DOI":"10.1016\/S0140-6736(14)60584-5"},{"key":"bibr6-17474930211021353","doi-asserted-by":"crossref","unstructured":"Bourcier R, Alexandre PL, Eug\u00e8ne F, et\u00a0al. Is bridging therapy still required in stroke due to carotid artery terminus occlusions?\n                      J Neurointerv Surg\n                      . Epub ahead of print 2018. DOI: 10.1136\/neurintsurg-2017-013398.","DOI":"10.1136\/neurintsurg-2017-013398"},{"key":"bibr7-17474930211021353","doi-asserted-by":"crossref","unstructured":"Desilles JP, Loyau S, Syvannarath V, et\u00a0al. Alteplase reduces downstream microvascular thrombosis and improves the benefit of large artery recanalization in stroke.\n                      Stroke\n                      . Epub ahead of print 2015. DOI: 10.1161\/STROKEAHA.115.010721.","DOI":"10.1161\/STROKEAHA.115.010721"},{"key":"bibr8-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.017320"},{"key":"bibr9-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1136\/neurintsurg-2018-013834"},{"key":"bibr10-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.120.031477"},{"key":"bibr11-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1016\/j.wneu.2017.08.040"},{"key":"bibr12-17474930211021353","unstructured":"Bridging thrombolysis versus direct mechanical thrombectomy in acute ischemic stroke, ClinicalTrials.gov, https:\/\/clinicaltrials.gov\/ct2\/show\/NCT03192332 (accessed 9 May 2021)."},{"key":"bibr13-17474930211021353","unstructured":"DIRECT-SAFE: A randomized controlled trial of DIRECT endovascular clot retrieval versus standard bridging thrombolysis with endovascular clot retrieval, ClinicalTrials.gov, https:\/\/clinicaltrials.gov\/ct2\/show\/NCT03494920 (accessed 9 May 2021)."},{"key":"bibr14-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2001123"},{"key":"bibr15-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2020.23523"},{"key":"bibr16-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2020.23522"},{"key":"bibr17-17474930211021353","unstructured":"Roos Y, LeCouffe N, Kappelhof M, et\u00a0al. Intravenous thrombolysis followed by endovascular thrombectomy versus direct endovascular thrombectomy: a randomized controlled trial. In:\n                      International stroke conference\n                      , 18 March 2021."},{"key":"bibr18-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehs099"},{"key":"bibr19-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.119.025080"},{"key":"bibr20-17474930211021353","doi-asserted-by":"crossref","unstructured":"Schumi J and Wittes JT. Through the looking glass: understanding non-inferiority.\n                      Trials\n                      . Epub ahead of print 2011. DOI: 10.1186\/1745-6215-12-106.","DOI":"10.1186\/1745-6215-12-106"},{"key":"bibr21-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2005.07.062"},{"key":"bibr22-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.119.026717"},{"key":"bibr23-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.117.017496"},{"key":"bibr24-17474930211021353","doi-asserted-by":"crossref","unstructured":"Ohara T, Menon BK, Al-Ajlan FS, et\u00a0al. Thrombus migration and fragmentation after intravenous alteplase treatment: The INTERRSeCT study.\n                      Stroke\n                      2020; 203\u2013212.","DOI":"10.1161\/STROKEAHA.120.029292"},{"key":"bibr25-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.116.014181"},{"key":"bibr26-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1007\/s00062-016-0533-0"},{"key":"bibr27-17474930211021353","doi-asserted-by":"publisher","DOI":"10.1136\/neurintsurg-2018-014260"},{"key":"bibr28-17474930211021353","doi-asserted-by":"crossref","unstructured":"Katsanos AH, Safouris A, Sarraj A, et\u00a0al. Intravenous thrombolysis with tenecteplase in patients with large vessel occlusions: systematic review and meta-analysis.\n                      Stroke\n                      2021; 308\u2013312.","DOI":"10.1161\/STROKEAHA.120.030220"},{"key":"bibr29-17474930211021353","doi-asserted-by":"publisher","DOI":"10.20452\/pamw.15791"}],"container-title":["International Journal of Stroke"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/17474930211021353","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/17474930211021353","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/17474930211021353","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T07:19:49Z","timestamp":1777706389000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/17474930211021353"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,2]]},"references-count":29,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2021,8]]}},"alternative-id":["10.1177\/17474930211021353"],"URL":"https:\/\/doi.org\/10.1177\/17474930211021353","relation":{},"ISSN":["1747-4930","1747-4949"],"issn-type":[{"value":"1747-4930","type":"print"},{"value":"1747-4949","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,2]]}}}