Acute ischaemic stroke (AIS) is a major contributor to global mortality and disability [1], [2]. For the last two decades, the standard treatment for AIS patients arriving at the hospital within the recommended 4.5-hour treatment window has been intravenous thrombolysis (IVT) using alteplase [1], [3]. Ischemic infarcts, specifically cardioembolic stroke and atherothrombotic stroke, demonstrate the highest in-hospital mortality rates among the ischemic stroke subtypes. The short-term prognosis for individuals with cardioembolic stroke and atherothrombotic stroke is notably worse when contrasted with other subtypes of ischemic stroke [4].

Administration of IVT before endovascular treatment (EVT) is referred to as bridging therapy (BT) [5]. This approach is believed to expedite the thrombectomy procedure and reduce the need for multiple catheterization attempts using stent retrievers or aspiration systems. Additionally, IVT can aid in dissolving any remaining thrombotic material after mechanical thrombectomy [6]. In specific stroke cases, such as cardioembolic stroke, IVT may exhibit enhanced efficacy compared with strokes with an atherothrombotic etiology. IVT can be promptly initiated, particularly in patients transferred from another medical facility [5]. Furthermore, uncertainty remains regarding whether BT leads to an increased incidence of symptomatic intracerebral hemorrhage [7].

EVT for acute ischemic stroke has garnered significant attention in the field of stroke management since 2015 when multiple randomized controlled trials (RCTs) were published. These studies offer substantial evidence to support the potential improvement in outcomes for specific patient groups[8], [9], [10], [11], [12], [13]. When the Middle cerebral artery (MCA) main stem is blocked, EVT has demonstrated superior effectiveness compared with Intravenous Thrombolysis (IVT)[14], [15], [16]. However, it should be noted that EVT might be linked to a higher incidence of early symptomatic intracerebral haemorrhage, and its successful application requires the expertise of a specialized interventional team [14], [15], [16], [17]. Furthermore, EVT is constrained by "door-to-needle" time, which can be longer than that required for IVT owing to the additional catheterization time. Combining IVT and EVT offers the advantage of rapid initiation of thrombolysis through the intravenous route, while simultaneously achieving a higher recanalization rate through the intra-arterial approach.

To date, there continues to be a contentious debate regarding the effectiveness and safety of using IVT as an adjunctive therapy alongside EVT in patients with acute large vessel occlusion (LVO) in the anterior cerebral circulation. Numerous meta-analyses and observational investigations have suggested that administering IVT before EVT may not yield additional benefits in patients undergoing EVT [18], [19], [20], [21]. Conversely, some studies have demonstrated enhanced outcomes in patients receiving combined EVT and IVT [20], [22], [23], [24], [25].