BACKGROUND: It was uncertain if direct endovascular thrombectomy (ET) was superior to bridging thrombolysis (BT) for patients with acute ischemic stroke caused by large-vessel occlusions. We aimed to examine real-world clinical outcomes of ET using nationwide registry data in China and to compare the efficacy and safety between BT and direct ET. METHODS AND RESULTS: Patients treated with ET from a nationwide registry study in China were included. Rapid neurological improvement, intracranial hemorrhage, and in-hospital mortality were compared between the 2 groups using multivariate logistic models and propensity-score matching analyses. A total of 7674 patients from 592 stroke centers were included. The median onset-to-puncture time, onset-to-door time, and door to puncture time were 290, 170, and 99 minutes, respectively. A total of 2069 (27.0%) patients received BT treatment. Patients in the BT group had a significantly shorter onset-to-puncture time (235 versus 323 minutes; P<0.001) and onset-to-door time (90 versus 222 minutes; P<0.001) compared with the direct ET group. The prior use of intravenous thrombolysis was associated with a higher rate of rapid neurological improvement (adjusted odds ratio [OR], 0.83; 95% CI, 0.71–0.96) and higher risk of intracranial hemorrhage (adjusted OR, 1.46; 95% CI, 1.18–1.80) in multivariate analyses and propensity-score matching analyses. CONCLUSIONS: This study reflects the current application of ET in China. More patients received direct ET than BT. Our results suggested that favorable short-term outcomes could be achieved with BT compared with direct ET. Higher risk of intracranial hemorrhage was observed in the BT group. © 2021 The Authors.