Endovascular Therapy Versus Best Medical Treatment in Posterior Cerebral Artery Stroke: A Systematic Review and Meta‐Analysis

Background: Intra-arterial thrombolytics have emerged as a potential adjunct to endovascular thrombectomy in patients with acute ischemic stroke, due to suboptimal functional outcomes associated with thrombectomy alone. Several studies have evaluated the safety and efficacy of intra-arterial tenecteplase as an adjunctive therapy; however, findings remain variable. To address this, we conducted a systematic review and meta-analysis to synthesize the available evidence. Research question: Does adjunctive intra-arterial tenecteplase improve freedom from disability in patients with acute ischemic stroke without increasing the risk of symptomatic intracranial hemorrhage or mortality when compared to endovascular thrombectomy alone? Methods: We systematically searched PubMed, Cochrane, Embase and conference abstracts for studies comparing intra-arterial tenecteplase as an adjunct to endovascular thrombectomy versus endovascular thrombectomy alone in patients with acute ischemic stroke. The efficacy outcome was freedom from disability as measured by a modified Rankin Scale (mRS) score of 0 or 1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and mortality at 90 days. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random effects model. Heterogeneity was assessed using I2 statistics. Results: We included 1226 patients from six studies, of which three were randomised controlled trials. A total of 578 patients (47%) were treated with intra-arterial tenecteplase in addition to endovascular thrombectomy. Treatment with adjunctive intra-arterial tenecteplase was associated with an increased likelihood of freedom from disability compared to endovascular thrombectomy alone (RR 1.2; 95% CI 1.01-1.41; p=0.03; I2 =7%; Figure 1A). There was no significant difference in symptomatic hemorrhage (RR 1.31; 95% CI 0.81-2.12; p=0.27; I2=0%; Figure 1B) and mortality at 90 days (RR 0.92; 95% CI 0.73-1.15; p=0.46; I2=0%) in the intra-arterial tenecteplase group compared to endovascular thrombectomy alone. These findings were consistent in a subgroup analysis restricted to randomized controlled trials. Conclusion: In patients with acute ischemic stroke, adjunctive intra-arterial tenecteplase was associated with a higher likelihood of freedom from disability compared to endovascular therapy alone, without a corresponding increase in symptomatic intracranial hemorrhage or 90-day mortality.

Endovascular thrombectomy for acute ischemic stroke with a large infarct area: An updated systematic review and meta-analysis of randomized controlled trials

BackgroundSix randomized controlled trials have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for patients with large infarcts.To synthesize the results from six trials which met...

Several studies have shown an additional benefit of tirofiban administration in patients with acute ischemic stroke (AIS) who underwent reperfusion therapy. According to the last revised guidelines, the efficacy of tirofiban in treating AIS is not well-established. Therefore, we performed a meta-analysis to assess the efficacy and safety of reperfusion therapy with tirofiban compared to reperfusion therapy alone in treating AIS. We systematically searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) reporting the use of tirofiban combined with reperfusion therapy in AIS patients within 72h after the onset of symptoms with 90days minimum follow-up. We employed risk ratio (RR) and Mean Differences (MD) with 95% confidence intervals (CIs) as the measure of effect size using a random-effects model. We included seven RCTs comprising 1607 patients, of whom 815 (50.7%) received tirofiban combined with reperfusion therapy and 792 (49.3%) received reperfusion therapy alone (no-tirofiban). The addition of tirofiban to the reperfusion therapy resulted in a higher rate of favorable outcomes (RR 1.25; 95% CI 1.11-1.40; p < 0.001) with less functional disability (RR 0.72; 95% CI 0.53-0.98; p < 0.05). The administration of tirofiban significantly improved the National Institutes of Health Stroke Scale (NIHSS) after seven days (MD -2.27; 95% CI -4.32 to -0.22; p = 0.03). A similar rate of successful revascularization was observed between groups (RR 1.18; 95% CI 0.97-1.45; p = 0.09). Tirofiban did not increase the risk of symptomatic intracranial hemorrhage (sICH) (RR 1.47; 95% CI 0.98-2.19; p = 0.06), but increase the risk of any intracranial hemorrhage (ICH), particularly in the endovascular thrombectomy (EVT) subgroup analysis (RR 1.25; 95% CI 1.03-1.51; p = 0.02). Mortality rates were similar between groups RR 1.05; 95% CI 0.80-1.38; p = 0.72). The addition of tirofiban to reperfusion therapy was associated with improved functional outcomes, without a significant increase in ICH. NIHSS after seven days of stroke onset was significantly improved by tirofiban. There was an increase in any ICH events, particularly in EVT patients. Mortality was not significantly altered by tirofiban.

Should Patients ≥90 Years with Acute Ischemic Stroke Still Undergo Endovascular Thrombectomy?

About one in five strokes occur during sleep (wake-up stroke). People with wake-up strokes have previously been considered to be ineligible for thrombolytic treatment because the time of stroke onset is unknown. However, recent studies suggest benefit from recanalisation therapies in selected patients. To assess the effects of intravenous thrombolysis and endovascular thrombectomy versus control in people with acute ischaemic stroke presenting on awakening from sleep. We searched the Cochrane Stroke Group Trials Register (last search 24 of May 2021). In addition, we searched the following electronic databases in May 2021: Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 4 of 12, April 2021) in the Cochrane Library, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We searched the Stroke Trials Registry (last search 7 December 2017, as the site is currently inactive). We also screened references lists of relevant trials, contacted trialists, and undertook forward tracking of relevant references. Randomised controlled trials (RCTs) of intravenous thrombolytic drugs or endovascular thrombectomy treatments in people with acute ischaemic stroke presenting upon awakening. Two review authors applied the inclusion criteria, extracted data, and assessed risk of bias and the certainty of the evidence using the GRADE approach. We obtained both published and unpublished data for participants with wake-up strokes. We excluded participants with strokes of unknown onset if the symptoms did not begin upon awakening. We included seven trials with a total of 980 participants, of which five trials with 775 participants investigated intravenous thrombolytic treatment and two trials with 205 participants investigated endovascular thrombectomy in large vessel occlusion in the anterior intracranial circulation. All trials used advanced imaging for selecting patients to treat. For intravenous thrombolytic treatment, good functional outcome (defined as modified Rankin Scale score 0 to 2) at 90 days follow-up was observed in 66% of participants randomised to thrombolytic treatment and 58% of participants randomised to control (risk ratio (RR) 1.13, 95% confidence interval (CI) 1.01 to 1.26; P = 0.03; 763 participants, 5 RCTs; high-certainty evidence). Seven per cent of participants randomised to intravenous thrombolytic treatment and 10% of participants randomised to control had died at 90 days follow-up (RR 0.68, 95% CI 0.43 to 1.07; P = 0.09; 763 participants, 5 RCTs; high-certainty evidence). Symptomatic intracranial haemorrhage occurred in 3% of participants randomised to intravenous thrombolytic treatment and 1% of participants randomised to control (RR 3.47, 95% CI 0.98 to 12.26; P = 0.05; 754 participants, 4 RCTs; high-certainty evidence). For endovascular thrombectomy of large vessel occlusion, good functional outcome at 90 days follow-up was observed in 46% of participants randomised to endovascular thrombectomy and 9% of participants randomised to control (RR 5.12, 95% CI 2.57 to 10.17; P < 0.001; 205 participants, 2 RCTs; high-certainty evidence). Twenty-two per cent of participants randomised to endovascular thrombectomy and 33% of participants randomised to control had died at 90 days follow-up (RR 0.68, 95% CI 0.43 to 1.07; P = 0.10; 205 participants, 2 RCTs; high-certainty evidence). In selected patients with acute ischaemic wake-up stroke, both intravenous thrombolytic treatment and endovascular thrombectomy of large vessel occlusion improved functional outcome without increasing the risk of death. However, a possible increased risk of symptomatic intracranial haemorrhage associated with thrombolytic treatment cannot be ruled out. The criteria used for selecting patients to treatment differed between the trials. All studies were relatively small, and six of the seven studies were terminated early. More studies are warranted in order to determine the optimal criteria for selecting patients for treatment.

BackgroundPosterior cerebral artery (PCA) infarctions represent 5–10% of all acute ischemic strokes, often manifesting with visual and cognitive deficits that can substantially impair quality of life. Although endovascular thrombectomy (EVT) is an established treatment for large-vessel occlusions, its role in isolated PCA occlusion remains uncertain, with limited evidence and heterogeneous outcomes across studies. We conducted this systematic review and meta-analysis to compare the effictiveness and safety of EVT versus medical management (MM) in patients with acute PCA occlusion.MethodsA systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science were searched until July 2025. Eligible studies included randomized or cohort studies comparing EVT with MM in PCA occlusion. Primary outcomes were excellent (modified Rankin Scale [mRS] 0–1) and favorable (mRS 0–2) functional outcomes at 90 days. Secondary outcomes included change in National Institutes of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models.ResultsNine high-quality cohort studies including 57,287 patients (EVT = 2475; MM = 54,812) were analyzed. EVT was not associated with significant improvement in excellent (RR = 1.05; 95% CI, 0.91–1.21) or favorable (RR = 0.94; 95% CI, 0.84–1.05) functional outcomes compared to MM. Mortality (RR = 1.33; 95% CI, 0.99–1.80) and sICH (RR = 1.60; 95% CI, 0.87–2.93) rates were comparable between groups. However, EVT was associated with short-term neurological improvement on NIHSS at discharge (MD=-1.21; 95% CI, -1.96 to -0.46; p = 0.002).ConclusionsEVT for PCA was associated with short-term neurological improvement versus MM, with mortality and sICH remaining comparable. However, these benefits did not translate into superior long-term functional outcomes as measured by mRS. The unique clinical features of PCA stroke, particularly visual and cognitive impairments not adequately captured by global disability scales, may contribute to this discrepancy. High-quality randomized trials incorporating domain-specific outcomes are warranted to define the role of EVT in PCA occlusion.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12883-025-04512-x.

There is growing evidence for endovascular thrombectomy (EVT) in patients with large ischemic core infarct and large vessel occlusion (LVO). The objective of this study was to compare the efficacy and safety of EVT vs medical management (MM) using a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to mechanical thrombectomy for large ischemic core from inception until February 10, 2023. The primary outcome was independent ambulation (modified Rankin Scale [mRS] 0-3). Effect sizes were computed as risk ratio (RR) with random-effect or fixed-effect models. The quality of articles was evaluated through the Cochrane risk assessment tool and the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42023396232). A total of 5,395 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded by review of the title, abstract, and full text. Finally, 3 RCTs and 10 cohort studies met the inclusion criteria. The RCT analysis showed that EVT improved the 90-day functional outcomes of patients with large ischemic core with high-quality evidence, including independent ambulation (mRS 0-3: RR 1.78, 95% CI 1.28-2.48, p < 0.001) and functional independence (mRS 0-2: RR 2.59, 95% CI 1.89-3.57, p < 0.001), but without significantly increasing the risk of symptomatic intracranial hemorrhage (sICH: RR 1.83, 95% CI 0.95-3.55, p = 0.07) or early mortality (RR 0.95, 95% CI 0.78-1.16, p = 0.61). Analysis of the cohort studies showed that EVT improved functional outcomes of patients without an increase in the incidence in sICH. This systematic review and meta-analysis indicates that in patients with LVO stroke with a large ischemic core, EVT was associated with improved functional outcomes over MM without increasing sICH risk. The results of ongoing RCTs may provide further insight in this patient population.

Endovascular Thrombectomy for Large Core Volume Acute Ischemic Stroke. Updated Systematic Review and Meta-Analysis: Thrombectomy for large core acute ischemic strokes

Limited randomized controlled trials (RCTs) have been performed comparing endovascular thrombectomy (EVT) to medical therapy (MEDT) for acute ischemic stroke with extensive baseline ischemic injury (AIS-EBI). We conducted a systematic review and meta-analysis of RCTs reporting EVT for AIS-EBI. Using the Nested Knowledge AutoLit software, we conducted a systematic literature review from inception to 12 February 2023 within Web of Science, Embase, Scopus, and PubMed databases. Results of the TESLA trial were included on 10 June 2023. We included RCTs that compared EVT to MEDT for AIS with large ischemic core volume. The primary outcome of interest was a modified Rankin Score (mRS) 0-2. Secondary outcomes of interest included early neurological improvement (ENI), mRS 0-3, thrombolysis in cerebral infarction (TICI) 2b-3, symptomatic intracranial hemorrhage (sICH), and mortality. A random-effects model was used to calculate risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). We included four RCTs with 1310 patients, 661 of whom underwent EVT and 649 of whom were treated with MEDT. EVT was associated with greater rates of mRS 0-2 (RR = 2.33, 95% CI = 1.75-3.09; P-value < 0.001), mRS 0-3 (RR = 1.68, 95% CI = 1.33-2.12; P-value < 0.001), and ENI (RR = 2.24, 95% CI = 1.55-3.24; P-value < 0.001). Rates of sICH (RR = 1.99, 95% CI = 1.07-3.69; P-value = 0.03) were greater in the EVT group. Mortality (RR = 0.98, 95% CI = 0.83-1.15; P-value = 0.79) was comparable between the EVT and MEDT groups. The rate of successful reperfusion in the EVT group was 79.9% (95% CI = 75.6-83.6). Although the rate of sICH was greater in the EVT group, EVT conferred a greater clinical benefit to MEDT for AIS-EBI based on available RCTs.

Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra-arterial thrombolysis, or both, for acute ischaemic stroke. To assess whether endovascular thrombectomy or intra-arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke. We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers. Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke. Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow-up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow-up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow-up, neurological status at the end of follow-up, and degree of recanalisation. We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high-certainty evidence). Treatment also reduced the risk of death at end of follow-up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high-certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high-certainty evidence) or by end of follow-up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high-certainty evidence);however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; high-certainty evidence) and RR 3.11 (95% CI 2.18 to 4.42; 268 participants, 3 RCTs; high-certainty evidence), respectively. In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.

Background and Objectives:The optimal systolic blood pressure (SBP) control after endovascular thrombectomy (EVT) is unclear. This study aimed to determine whether intensive SBP control (<140 mmHg) within 24 h post-EVT, compared to conventional management (<180 mmHg), leads to a better functional outcome, defined as a modified Rankin Scale (mRS) score of 0–2 at 90 days.Methods:Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched databases (PubMed, Scopus, EMBASE, Google Scholar, Web of Science) for English language articles up to March 15, 2024. We included randomized controlled trials (RCTs) and observational studies comparing intensive versus conventional SBP control up to 24 h post-EVT. Studies without separate primary outcome data and case series/reports were excluded. The primary outcome was functional independence (mRS 0–2 at 90 days).Results:Twelve studies (n = 5152 patients; five RCTs and seven observational studies) were included, and a primary analysis of the RCTs, along with a secondary exploratory analysis of the observational studies were conducted. The analysis of RCTs favored conventional control for the primary outcome (risk ratio [RR]- 0.81; 95% confidence interval [CI]- 0.73–0.90; P < 0.0001). Mortality rates (RR- 1.14, 95% CI- 0.89–1.45; P = 0.29) and the risk of symptomatic intracranial hemorrhage (RR- 1.10, 95% CI- 0.77–1.58; P = 0.60) were similar in both groups. The secondary exploratory analysis of observational data favored the intensive arm for the primary outcome (RR- 1.28, 95% CI- 1.17–1.41; P < 0.00001).Conclusions:Our primary analysis of RCTs showed that intensive control was associated with poorer functional outcomes, with no significant impact on mortality rate or the risk of symptomatic intracranial hemorrhage. Although observational studies suggested better outcomes with intensive control, we recommend conventional management based on Level 1 evidence from RCTs.PROSPERO Registration no- CRD42023463173

Background: Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke due to large vessel occlusions. Despite the increasing evidence for EVT, its efficacy remains understudied in patients with acute ischemic stroke with large infarcts. Patients with large-volume ischemic strokes are excluded from major randomized controlled trials (RCTs) despite contributing up to 25% of all acute ischemic strokes. Aim: This study aimed to compare clinical outcomes with endovascular thrombectomy versus medical management in patients with acute ischemic stroke with large infarct. Methods: We conducted a systematic literature review on PubMed, Embase, Scopus and Cochrane Library from inception to 15th May 2024 for RCTs. The inverse-variance random-effects model was used to pool odds ratio (OR) and risk ratio (RR) with 95% confidence intervals. The statistical significance was set at p&lt;0.05. Results: 6 RCTs with 1887 patients (945: EVT and 942: medical management) were included. The mean age in both EVT and medical management groups was 70 ± 11.4 years. EVT was associated with a better modified Rankin Score (mRS) at 90 days [OR: 1.68; 95% CI: 1.38, 2.04; p&lt;0.00001], mRS at 90 days (0-2) [OR: 2.47; 95% CI: 1.87, 3.27; p&lt;0.00001], mRS at 90 days (0-3) [OR: 1.96; 95% CI: 1.56, 2.46; p&lt;0.00001], and early neurological improvement [RR: 2.35; 95% CI: 1.79, 3.10; p&lt;0.00001] compared to medical management. EVT was also associated with a higher risk of symptomatic intracranial hemorrhage [RR: 1.71; 95% CI: 1.09, 2.66; p=0.02]. The 90-day mortality [RR: 0.86; 95% CI: 0.72, 1.02; p=0.08] was comparable between the two groups. Conclusion: Patients with acute ischemic stroke with large infarct had superior functional outcomes with EVT as compared to medical management alone. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage, with comparable 90-day mortality risk. Further large RCTs are warranted to evaluate the outcomes with EVT in acute ischemic stroke with large infarct.

Background:Increased peak systolic velocity (PSV) in transcranial Doppler or Duplex sonography (TCD) of the middle cerebral artery (MCA) after endovascular thrombectomy (EVT) for large vessel occlusion in acute ischemic anterior circulation stroke has been associated with poor functional outcome and increased risk of symptomatic intracranial hemorrhage (ICH).Objective: We evaluated whether increased MCA-PSV is associated with the development of malignant media infarction after EVT.Methods:We retrospectively identified all patients who underwent EVT for acute anterior circulation ischemic stroke at our stroke center from January 2021 to July 2024. Increased MCA-PSV on TCD was defined as >30% mean PSV in the treated MCA compared with the contralateral MCA. The development of malignant media infarction was evaluated according to predefined clinical and neuroimaging criteria. Multivariable regression models were used to identify associations between MCA-PSV and the development of malignant media infarction.Results:Out of a total cohort of 377 patients, 49 (13.0%) developed malignant media infarction. In multivariable analysis, MCA-PSV increase was significantly associated with malignant media infarction (odds ratio (OR), 53.3 (95% confidence interval (CI): 18.74, 151.54); p < 0.001). Furthermore, the development of malignant media infarction was also associated with secondary ICH (OR, 6.4 (95% CI: 2.16, 19.03); p < 0.001) and higher baseline National Institutes of Health Stroke Scale (OR, 1.25 (95% CI: 1.14, 138); p < 0.001).Conclusion:Increased MCA-PSV can act as a predictive marker for the development of malignant media infarction. TCD may serve as a valuable bedside tool in individual risk assessment in early postinterventional surveillance.

Introduction/Purpose Endovascular thrombectomy (EVT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The role of intravenous thrombolysis (IVT) prior to EVT—commonly referred to as bridging therapy—remains controversial in elderly patients because of concerns regarding an increased risk of symptomatic intracranial hemorrhage (sICH). This study aims to compare the safety and efficacy of bridging therapy (IVT + EVT) versus EVT alone in patients aged ≥80 years. Materials/Methods We conducted a retrospective cohort study for AIS patients, aged ≥80 years, with LVO who underwent EVT (2021‐2025). Adjusted logistic regression models were used to estimate odds ratios (aOR) for key outcomes: improvement in 90‐day mRS scores, favorable outcomes (mRS 0‐2 or return to baseline), sICH, complete recanalization (TICI 3), and successful recanalization (TICI ≥2b). Results Among 295 patients, 71 received bridging IVT and 224 underwent EVT alone. The bridging IVT group had a significantly shorter hospital arrival time (187 [IQR: 115‐259] minutes vs. 449 [IQR: 230‐806] minutes), higher proportion of females (81.7% vs. 68.3%), and a lower prevalence of atrial fibrillation (49.3% vs. 68.8%). After adjusting for baseline confounders, bridging therapy was not significantly associated with any key outcomes: 90‐day mRS scores (aOR[FM1] 0.94, 95% CI: 0.50‐1.75, p=0.84), favorable outcomes (aOR 1.00, 95% CI: 0.46‐2.17, p=0.99), sICH (aOR 1.12, 95% CI: 0.30‐4.21, p=0.87), complete recanalization (aOR 0.91, 95% CI: 0.50‐1.64, p=0.74), or successful recanalization (aOR 1.00, 95% CI: 0.29‐3.45, p=0.99). Conclusion In this cohort of patients beyond octogenarians, bridging therapy with IVT prior to EVT was not independently associated with improved functional outcomes, including shifts in 90‐day mRS scores, nor with higher rates of recanalization. Importantly, it did not significantly increase the risk of symptomatic intracranial hemorrhage after adjustment for baseline characteristics. These findings suggest that EVT alone may be a safe and effective treatment strategy for elderly patients, particularly those presenting beyond the IVT time window or with contraindications to thrombolysis. IVT decisions in this population should be individualized, based on clinical presentation, symptom onset timing, and overall risk profile. image