Thrombus Migration Influences Outcomes of Endovascular Treatment in Acute Ischemic Stroke

Background Stroke is the world's second‐leading cause of death, with ischemic events accounting for nearly 9 of 10 cases. Rapid endovascular treatment (EVT) is now standard, yet the benefit of giving intravenous tPA beforehand (“bridging therapy”) remains uncertain. One reason: tPA often shifts the clot distally—thrombus migration (TM)—a phenomenon seen in roughly one‐fifth of large‐vessel strokes that can complicate the procedure but has also been linked to better outcomes. This study evaluates how TM influences clinical outcomes, aiming to clarify whether tPA adds value in patients who receive EVT. Methods A comprehensive literature search was conducted across various databases until April 2025 to identify relevant articles. The quality was assessed using the NOS tool and the analysis was performed using RevMan 5 software. Primary outcomes of interest were favorable functional outcomes (modified Rankin Scale score 0‐2) and mortality 90 days after stroke. Results Thirteen studies (n=6,198 patients) were identified fulfilling our research question. Thrombus migration was significantly associated with favourable neurological outcomes (mRS 0–2) at 90 days (OR=1.43; P=0.025) (Figure 1A). Meta‐analysis of five studies revealed no statistically significant difference in successful reperfusion rates (TICI 2b‐3) between thrombus migration and non‐migration groups (OR=0.69, 95% CI [0.46–1.03], P=0.07). Significant heterogeneity was identified (I 2 =74%; P=0.004) (Figure 1B). TM showed no significant impact on 90‐day mortality (OR=0.86; P=0.15) (figure 1C) or symptomatic intracranial hemorrhage (sICH) (OR=1.12; P=0.54) (figure 1D). However, TM was associated with increased any ICH (OR=1.55; P=0.043) (figure 1E). Conclusion Thrombus migration during mechanical thrombectomy was associated with better 90‐day functional outcomes, despite an increased risk of hemorrhagic events. Although thrombus migration complicates thrombectomy procedures, it may offer clinical benefits by restoring blood flow to larger brain territories. These findings support a nuanced role for thrombus migration, potentially favouring the use of IV thrombolysis in selected stroke patients undergoing mechanical thrombectomy.