Direct EVT vs Bridging IV Thrombolysis

Six RCTs tested whether direct EVT is noninferior to IV-thrombolysis-bridging in tPA-eligible LVO patients. DIRECT-MT (2020, China) and DEVT (2020, China) met noninferiority. SKIP (2020, Japan), MR CLEAN-NO IV (2021, Europe), SWIFT-DIRECT (2022, Europe), and DIRECT-SAFE (2022, multinational) did not meet noninferiority. Pooled evidence favors bridging for most tPA-eligible patients; AHA/ASA 2026 recommends IV thrombolysis should not be withheld in patients eligible for both treatments. Direct EVT is reasonable when tPA is contraindicated.

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Clinical Question

Direct thrombectomy or bridging with IV thrombolysis first?

Synthesises 7 trialsEVT-eligible LVO: skip the IVT or bridge? Six RCTs across China, Japan, Europe, and multinational

What does the guideline say?

§4.7.1 EVT Concomitant with IVT· 2026
In patients with AIS who are eligible for both IVT and EVT, IVT is safe and recommended to improve overall reperfusion efficacy and clinical outcomes (COR 1, LOE A). In patients with AIS who are eligible for both IVT and EVT, IVT should be administered as rapidly as possible, without observation, to assess clinical response or delay in initiating EVT, to improve treatment times and clinical outcomes (COR 1, LOE A).
Source: 2026 AHA/ASA Guideline · §4.7.1 (EVT Concomitant with IVT)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 7

THRACE2016

NNT 9OR 1.55 (1.05–2.30)

Bridging EVT after IV tPA raised independence from 42% to 53% in proximal LVO ≤5 h.

NNT 9OR 1.55 (1.05–2.30)

DIRECT-MT2020

Non-inferiorcOR 1.07 (0.81–1.40)

Direct EVT met noninferiority vs bridging in Chinese centers; CI margin narrow.

Non-inferiorcOR 1.07 (0.81–1.40)

DEVT2021

Non-inferior+7.7% (1-sided 97.5% CI -5.1)