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Meta-Analysis
. 2023 Aug 29;101(9):e922-e932.
doi: 10.1212/WNL.0000000000207536. Epub 2023 Jun 5.

Mechanical Thrombectomy for Large Ischemic Stroke: A Systematic Review and Meta-analysis

Qi Li  1 , Mohamad Abdalkader  1 , James E Siegler  1 , Shadi Yaghi  1 , Amrou Sarraj  1 , Bruce C V Campbell  1 , Albert J Yoo  1 , Osama O Zaidat  1 , Johannes Kaesmacher  1 , Deep Pujara  1 , Raul G Nogueira  1 , Jeffrey L Saver  1 , Lei Li  1 , Qin Han  2 , Yi Dai  1 , Hongfei Sang  1 , Qingwu Yang  1 , Thanh N Nguyen  2 , Zhongming Qiu  2
Affiliations
Meta-Analysis

Mechanical Thrombectomy for Large Ischemic Stroke: A Systematic Review and Meta-analysis

Qi Li et al. Neurology. .

Abstract

Background and objectives: There is growing evidence for endovascular thrombectomy (EVT) in patients with large ischemic core infarct and large vessel occlusion (LVO). The objective of this study was to compare the efficacy and safety of EVT vs medical management (MM) using a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs).

Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to mechanical thrombectomy for large ischemic core from inception until February 10, 2023. The primary outcome was independent ambulation (modified Rankin Scale [mRS] 0-3). Effect sizes were computed as risk ratio (RR) with random-effect or fixed-effect models. The quality of articles was evaluated through the Cochrane risk assessment tool and the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42023396232).

Results: A total of 5,395 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded by review of the title, abstract, and full text. Finally, 3 RCTs and 10 cohort studies met the inclusion criteria. The RCT analysis showed that EVT improved the 90-day functional outcomes of patients with large ischemic core with high-quality evidence, including independent ambulation (mRS 0-3: RR 1.78, 95% CI 1.28-2.48, p < 0.001) and functional independence (mRS 0-2: RR 2.59, 95% CI 1.89-3.57, p < 0.001), but without significantly increasing the risk of symptomatic intracranial hemorrhage (sICH: RR 1.83, 95% CI 0.95-3.55, p = 0.07) or early mortality (RR 0.95, 95% CI 0.78-1.16, p = 0.61). Analysis of the cohort studies showed that EVT improved functional outcomes of patients without an increase in the incidence in sICH.

Discussion: This systematic review and meta-analysis indicates that in patients with LVO stroke with a large ischemic core, EVT was associated with improved functional outcomes over MM without increasing sICH risk. The results of ongoing RCTs may provide further insight in this patient population.

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Conflict of interest statement

J. Kaesmacher is supported by the grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, Clinical Trials Unit Bern, and the Swiss National Science Foundation. A. Sarraj is Principal Investigator of the SELECT2 trial funding by grants from Stryker Neurovascular to University of Texas-McGovern Medical School and University Hospitals—Cleveland Medical Center. J.L. Saver has received contracts from Medtronic, Abbott, NeuroVasc, Phillips Medical, Bayer, Biogen, Roche, BrainsGate, BrainQ, and Occlutech and stock options from Rapid Medical and QuantalX for service on clinical trial steering committees and Data and Security Monitoring Committees and advising on rigorous study design and conduct. T.N. Nguyen received research support from Medtronic and served on advisory board of Idorsia. R.G. Nogueira reports consulting fees from Anaconda, Biogen, Cerenovus, Genentech, Philips, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby and Synchron and stock options from Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze for advisory serve; is the Principal Investigator of the “Combined Thrombectomy for Distal MediUm Vessel Occlusion StroKe (DUSK)” trial funding by Stryker Neurovascular; and is an Investor in Viz-AI, Perfuze, Cerebrotech, Reist/Q'Apel Medical, Truvic, Vastrax, and Viseon. A.J. Yoo and O.O. Zaidat report PI of the Thrombectomy for Emergent Salvage of Large Anterior Ischemic Stroke (TESLA) trial. The remaining authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Figures

Figure 1
Figure 1. PRISMA Flow Diagram
PRISMA = Preferred Reporting Items for Systematic Review and Meta-Analysis; RCT = randomized controlled trial.
Figure 2
Figure 2. Forest Plots of RCTs About (A) Independent Ambulation (mRS ≤3), (B) Functional Independence (mRS ≤2), (C) Incidence of sICH (per Study Definition), and (D) Mortality
EVT = endovascular thrombectomy; MM = medical management; mRS = modified Rankin Scale; RCT = randomized controlled trial; sICH = symptomatic intracranial hemorrhage.
Figure 3
Figure 3. Forest Plots of Observational Cohort Studies About (A) Independent Ambulation (mRS ≤3), (B) Functional Independence (mRS ≤2), (C) Incidence of sICH, and (D) Mortality
EVT = endovascular thrombectomy; MM = medical management; mRS = modified Rankin Scale; RCT = randomized controlled trial; sICH = symptomatic intracranial hemorrhage.
See this image and copyright information in PMC

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