OBJECTIVES: Preliminary evidence indicates that intra-arterial (IA) thrombolysis is a more effective treatment for a subgroup of ischemic stroke patients who have a visible intracranial occlusion than intravenous (IV) thrombolysis. This cost-utility analysis compares four treatment strategies for ischemic stroke: conservative treatment, IV thrombolysis, IA thrombolysis and a bridging strategy of both IV and IA thrombolysis (with or without mechanical thrombectomy). METHODS: A health economic model was developed that compared the four different treatments. A decision tree with a Markov model was used to assess 6 months- and lifetime costs (in Euros) and effects (in QALYs) of these different treatment strategies. A literature search provided the estimates used in the decision tree and data from the EDISSE trial was used for cost estimates, combined with cost estimates from Erasmus MC University Hospital Rotterdam on IA thrombolysis. Current Dutch epidemiological information was used in the Markov model to calculate lifetime costs and effects for all treatment strategies. RESULTS: From a lifetime perspective, IV thrombolysis is the dominant treatment strategy: it saves €1717 per QALY gained compared to the conservative treatment. The bridging strategy costs an additional €7217 per QALY gained compared to IV thrombolysis. IA thrombolysis is dominated by the other strategies as it gains equal QALYs as IV thrombolysis while it is a slightly more expensive treatment. A probabilistic sensitivity analysis shows that depending on the willingness to pay, these treatment strategies are cost-effective at six months in 84 percent of cases. CONCLUSIONS: The bridging strategy significantly improves functional outcome of acute ischemic stroke patients at reasonable additional costs. However, more empirical studies need to be performed in order to reduce the considerable amount of uncertainty concerning the costs and effects of IA thrombolysis for acute ischemic stroke.