Outcomes after direct thrombectomy versus combined thrombolysis and thrombectomy in acute large artery occlusion stroke with atrial fibrillation

Background The role of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) remains controversial, particularly for patients with acute large vessel occlusion (LVO) due to atrial fibrillation (AF), who may have a poor response to thrombolysis. Furthermore, robust evidence is lacking regarding the benefits of bridging therapy in patients with AF-related AIS-LVO. Accordingly, this study aimed to assess whether patients with AF benefit from bridging thrombectomy. Methods We performed a retrospective, observational, single-center study from January 2020 to June 2025. Patients meeting the inclusion criteria for both IVT and EVT were enrolled and dichotomized based on thrombectomy type: the bridging thrombectomy (IVT + EVT) group versus the direct thrombectomy (EVT alone) group. After 1:1 propensity score matching (PSM), the outcome measures, including the proportions of patients with modified Rankin scale (mRS) scores of 0–2 at 90 days, the number of retrieval attempts, successful recanalization, door-to-recanalization time, symptomatic intracranial hemorrhage, and mortality within 90 days, were compared. Finally, an exploratory subgroup analysis was performed, stratifying the cohort by age. Results A total of 221 patients who underwent EVT were included (125 with bridging IVT and 96 with direct EVT). After PSM, there were no significant differences in 90-day functional independence (mRS 0–2) between the two groups (59.0% versus 50.0%; p = 0.158). Furthermore, direct EVT was associated with a shorter median door-to-recanalization time (125.5 versus 135.5 min; p = 0.015) and fewer median thrombectomy passes (1 versus 2, p = 0.003). The rates of successful recanalization, symptomatic intracranial hemorrhage, and 90-day mortality were comparable. A significant interaction effect between age and treatment modality was observed for the primary outcome of a 90-day mRS score of 0–2 ( p for interaction = 0.048). Among patients aged ≥85 years, those receiving EVT alone had a significantly higher rate of functional independence than those in the combined IVT and EVT groups (50.0% versus 12.5%, p = 0.041). Conclusion In this real-world, matched-control study, EVT alone demonstrated comparable efficacy to combined IVT + EVT for AF-related LVO. However, in patients aged ≥85, EVT alone significantly improved functional independence and reduced mortality.