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Efficacy and Safety of Bridging Intravenous Thrombolysis in the "Drip-and-Ship" Model for Anterior and Posterior Circulation Stroke: A Systematic Review and Meta-Analysis.

Luiz Filipe Paulo Rodrigues, Barbara Figueiredo Bonatti, Pandora Eloa Oliveira Fonseca, Davi Ricardo Amorim, Raíssa Estevam, Renata Tarraf Fernandes, Afonso Henrique Dutra-Melo

Journal of Vascular and Interventional Radiology · 2026-10-24 · Meta-analysis

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Abstract

PURPOSE: The drip-and-ship paradigm extends access to endovascular thrombectomy (EVT) from primary stroke centers (PSC), particularly where comprehensive stroke centers (CSC) are limited, but transfer may delay reperfusion. We evaluated the efficacy and safety of intravenous thrombolysis (IVT) before transfer for EVT in patients with large vessel occlusion (LVO) stroke. MATERIALS AND METHODS: We systematically searched PubMed, Embase, and the Cochrane Library through March 2026 for studies comparing IVT versus no IVT in patients transferred from PSC to CSC for EVT consideration. Random-effects models were used for pooled analyses. Heterogeneity was quantified by I2 and prediction intervals (PI). RESULTS: Sixteen observational studies involving 5,488 patients were included. In anterior circulation stroke, IVT was associated with higher odds of functional independence (mRS 0-2; aOR 1.76; P=0.02; 95% PI 0.67-4.63, including the null) and lower 90-day mortality (aOR 0.52; P<0.0001). In posterior circulation stroke, IVT was associated with lower mortality (RR 0.74; P=0.04), but not improved functional outcomes. IVT was associated with higher early recanalization during transfer in anterior (RR 5.24; P<0.0001) and posterior circulation (RR 17.46; P<0.0001), without significant differences in post-EVT revascularization or intracranial hemorrhage. All included studies were observational, and certainty of GRADE evidence was very low. CONCLUSION: IVT before transfer was associated with higher early recanalization and favorable clinical outcomes, particularly in anterior circulation stroke, without a detected increase in intracranial hemorrhage. Given the very-low certainty of evidence, these findings should be interpreted cautiously. Identified methodological limitations also informed considerations for future research.

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Tags

Antithrombotics & thrombolytics · Interfacility & critical care transport · Mortality & survival · Quality of life & function · Thrombolytics

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