Abstract Background and aims With recent randomized controlled trials of endovascular therapy (EVT) in medium vessel occlusion (MeVO) showing neutral outcomes, optimizing acute reperfusion strategies in MeVO remains a key evidence gap. The benefit of intravenous thrombolysis (IVT) before EVT in acute ischemic stroke with MeVO remains uncertain. We compared bridging IVT plus EVT with EVT alone in a real-world multicenter registry. Methods Based on the REperfusion therapy for acute ischemic STrOke due to large aRtEry occlusion (RESTORE) registry, patients with computed tomography angiography confirmed MeVO and treated with EVT were grouped into bridging IVT plus EVT versus EVT alone. The primary outcome was 90-day modified Rankin Scale (mRS) distribution. We used propensity score overlap weighting, followed by weighted ordinal logistic regression to estimate a common odds ratio (cOR) for the effect. Safety outcomes included symptomatic intracranial hemorrhage (sICH) within 36 hours, and 90-day death. Results Among 140 eligible patients (41 bridging IVT plus EVT, 99 EVT alone), bridging therapy achieved better functional outcomes (cOR 2.56, 95% confidence interval CI 1.23 to 5.35; P=0.012) and higher rate of mRS 0 to 1 at 90 days (50.0% vs 29.3%; relative risk RR 1.80, 95% CI 1.07 to 3.05). Symptomatic intracranial hemorrhage was numerically decreased (2.4% vs 8.1%) and the rate of death was significantly lower (0 vs 11.6%, risk difference -0.16, 95% CI -0.26 to -0.05) after bridging therapy. Conclusions In this real-world study, bridging therapy was associated with better functional outcome without increasing safety concerns in patients with MeVOs. Randomized trials are warranted. Conflict of interest All the authors: nothing to disclose.
Ma et al. (2026) studied this question.