Bridging Thrombolysis Versus Direct Mechanical Thrombectomy in Acute Ischemic Stroke - SWIFT DIRECT

Contribution To Literature:

The SWIFT DIRECT trial failed to show noninferiority of thrombectomy alone compared with alteplase plus thrombectomy.


The goal of the trial was to evaluate stent-retriever thrombectomy compared with intravenous (IV) alteplase plus stent-retriever thrombectomy among individuals presenting with acute ischemic stroke.

Study Design

  • Randomization
  • Parallel
  • Open-label
  • Stratified

Patients with acute ischemic stroke were randomized to stent-retriever thrombectomy (n = 201) versus IV alteplase plus stent-retriever thrombectomy (n = 207). Alteplase was given at a dose of 0.9 mg/kg to maximum of 90 mg.

  • Total number of enrollees: 408
  • Duration of follow-up: 90 days
  • Mean patient age: 73 years
  • Percentage female: 52%

Inclusion criteria:

  • Patients presenting with acute ischemic stroke due to large vessel occlusion within 4.5 hours of symptom onset

Principal Findings:

The primary outcome, Rankin score 0−2 at 90 days, occurred in 57% of the thrombectomy group vs. 65% of the alteplase plus thrombectomy group (adjusted risk difference −7.3%, 95% CI −16.6 to 2.1, lower limit of one-sided 95% CI −15.1%).

Secondary outcomes:

  • Symptomatic intracranial hemorrhage: 2% of the thrombectomy group vs. 3% of the alteplase plus thrombectomy group (risk difference −1.0%, 95% CI −4.8 to 2.7)


Among patients presenting with acute ischemic stroke, SWIFT DIRECT failed to show noninferiority of stent-retriever thrombectomy. Symptomatic intracranial hemorrhage was similar between treatment groups. Among patients with acute ischemic stroke undergoing stent-retriever thrombectomy, omitting IV alteplase cannot be recommended.


Fischer U, Kaesmacher J, Strbian D, et al., on behalf of the SWIFT DIRECT Collaborators. Thrombectomy alone versus intravenous alteplase plus thrombectomy in patients with stroke: an open-label, blinded-outcome, randomized non-inferiority trial. Lancet 2022;400:104-15.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Lipid Metabolism, Interventions and Vascular Medicine

Keywords: Coronary Occlusion, Geriatrics, Intracranial Hemorrhages, Ischemic Stroke, Risk, Stents, Stroke, Thrombectomy, Tissue Plasminogen Activator, Vascular Diseases

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