Endovascular treatment for large-core ischaemic stroke: a meta-analysis of randomised controlled clinical trials

Abstract

Background and purpose: Current guidelines recommend endovascular treatment (EVT) for acute ischaemic stroke (AIS), due to large-vessel occlusion and an Alberta Stroke Program Early CT Score (ASPECTS) of ≥6. High-quality evidence resulting from randomised controlled clinical trials (RCTs) regarding EVT among large-core AIS has recently become available, justifying an updated meta-analysis aiming to evaluate efficacy and safety of EVT in this clinical setting.

Methods: We conducted a systematic review and meta-analysis including all available RCTs that compared EVT in addition to best medical treatment (BMT) versus BMT alone for large-core AIS (defined by ASPECTS 2-5 or volumetric methods). The primary outcome was reduced disability at 3 months (≥1-point reduction across all Modified Rankin Scale (mRS) grades). Secondary outcomes included independent ambulation at 3 months (mRS score 0-3), good functional outcome at 3 months (mRS score 0-2), excellent functional outcome at 3 months (mRS score 0-1), symptomatic intracranial haemorrhage (sICH) and any intracranial haemorrhage (ICH) and mortality at 3 months. The random-effects model was used.

Results: Four RCTs were included comprising a total of 662 patients treated with EVT vs 649 patients treated with BMT. Compared with BMT, EVT was significantly associated with reduced disability (common OR 1.70, 95% CI 1.39 to 2.07; I²=0%), independent ambulation (risk ratio (RR) 1.69, 95% CI 1.33 to 2.14; I²=39%) and good functional outcome (RR 2.33, 95% CI 1.76 to 3.10; I²=0%), but not with excellent functional outcome (RR 1.46, 95% CI 0.91 to 2.33; I²=39%) at 3 months. Although rates of sICH (RR 1.98, 95% CI 1.07 to 3.68; I²=0%) and any ICH (RR 2.13, 95% CI 1.70 to 2.66; I²=37%) were higher in the EVT group, 3-month mortality (RR 0.98, 95% CI 0.83 to 1.15; I²=0%) did not differ between the two groups.

Conclusion: EVT appears to be effective and safe and may be considered for the treatment of large-core AIS, as assessed by ASPECTS of 2-5 or volumetric methods.

Prospero registration number: CRD42022334417.