Bridging therapy versus direct endovascular thrombectomy in basilar artery occlusion stroke: a systematic review and meta-analysis.

The benefits and safety of bridging therapy in basilar artery occlusion remain unclear, although current guidelines recommend it based on weak evidence and analogy to anterior circulation strokes. This study compares bridging intravenous thrombolysis and endovascular thrombectomy versus direct endovascular thrombectomy in a larger-than-ever basilar artery occlusion Population. Embase, PubMed, Scopus, Web of Science, and Cochrane Library were systematically searched. Studies that reported 90-day functional independence (mRS: 0-2), 90-day independent ambulation (mRS: 0-3), successful recanalization, symptomatic intracranial hemorrhage, any type of intracranial hemorrhage, and 90-day mortality were included. Two reviewers independently extracted data and assessed bias using ROBINS-I. A random-effects model was used. The protocol was registered in PROSPERO (CRD42024519161). Fifty-eight studies with 9372 subjects were included in the final analysis. Bridging therapy was associated with higher 90-day functional independence (OR 1.46; 95% CI 1.22-1.76; p < 0.001) and lower 90-day mortality (OR 0.63; 95% CI 0.49-0.82; p = 0.002). No significant differences were found in recanalization rate (OR 0.97; 95% CI 0.79-1.18; p = 0.707) or symptomatic intracranial hemorrhage (OR 0.88; 95% CI 0.65-1.18; p = 0.330). Benefits were consistent across subgroups defined by stroke severity, treatment window, occlusion site, and study site. Bridging therapy for basilar artery occlusion patients leads to a higher rate of functional independence and lower mortality without increasing the rate of intracranial hemorrhage compared to direct endovascular thrombectomy consistently across all subgroups.