Efficacy and safety of endovascular thrombectomy in acute ischemic stroke with large ischemic cores: A meta-analysis of randomized controlled trials and cohort studies

Abstract

Background: The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic infarcts have been the focus of recent research, yet discrepancies persist between studies. This meta-analysis evaluates the efficacy and safety of EVT using data from randomized controlled trials (RCTs) and real-world cohort studies.

Methods: A systematic search of PubMed, Web of Science, and Embase from January 1, 2010, to June 17, 2024, identified studies reporting favorable functional outcome (FFO), moderate functional outcome (MFO), symptomatic intracranial hemorrhage (sICH), mortality, early neurologic improvement (ENI), and other outcomes.

Results: Six RCTs and 21 cohort studies with 5,919 patients were analyzed. EVT significantly improved FFO (RR 2.49, 95% CI 1.89–3.29), MFO (RR 1.92, 95% CI 1.50–2.44), ENI (RR 2.34, 95% CI 1.77–3.09), and mRS shift (Generalized OR 1.45, 95% CI 1.32–1.61; Common OR 2.03, 95% CI 1.49–2.75) at 90 days compared to best medical treatment. EVT did not significantly increase sICH risk (RR 1.68, 95% CI 0.99–2.84; RR 1.61, 95% CI 0.80–3.23) or mortality (RR 0.86, 95% CI 0.72–1.02) but was associated with a higher incidence of any intracranial hemorrhage (ICH) (RR 1.74, 95% CI 1.28–2.36). Rates of early neurological worsening and decompressive craniectomy were similar between groups. Findings from RCTs and real-world cohort studies were consistent, reinforcing the robustness of the results.

Conclusion: EVT improves functional outcomes in patients with large ischemic cores without increasing the risk of sICH or mortality, though it is associated with a higher incidence of ICH. Further studies are necessary to refine patient selection and confirm long-term benefits.