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Review
. 2023 May;25(2):214-222.
doi: 10.5853/jos.2023.00752. Epub 2023 May 30.

Endovascular Thrombectomy for Large Ischemic Strokes: A Living Systematic Review and Meta-Analysis of Randomized Trials

Rami Z Morsi  1 , Mohamed Elfil  2 , Hazem S Ghaith  3 , Mohammad Aladawi  2 , Ahmad Elmashad  4 , Sachin Kothari  1 , Harsh Desai  1 , Shyam Prabhakaran  1 , Fawaz Al-Mufti  5 , Tareq Kass-Hout  1
Affiliations
Review

Endovascular Thrombectomy for Large Ischemic Strokes: A Living Systematic Review and Meta-Analysis of Randomized Trials

Rami Z Morsi et al. J Stroke. 2023 May.

Abstract

Background and purpose: New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only.

Methods: We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach.

Results: Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only.

Conclusion: Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

Keywords: GRADE; Large infarct; Low ASPECTS; Systematic review; Thrombectomy.

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Conflict of interest statement

Conflicts of interest

The authors completed the ICMJE Disclosure Forms and declare no competing interests.

Figures

Figure 1.
Figure 1.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. *Consider, if feasible to do so, reporting the number of records identified from database or register searched (rather than the total number across all databases/registers). Adapted from Page et al. J Clin Epidemiol 2021;134:178-189, under the Creative Commons license (CC-BY).[11] For more information, visit http://www.prisma-statement.org.
Figure 2.
Figure 2.
Forest plot for endovascular thrombectomy versus medical management only for functional independence defined as modified Rankin Scale score of 0 to 2 at 90 days. ANGEL-ASPECT, Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core; SELECT- 2, A Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke; RESCUE-Japan LIMIT, Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Large IscheMIc core Trial; CI, confidence interval.
Figure 3.
Figure 3.
Forest plot for endovascular thrombectomy versus medical management only for mortality at 90 days. ANGEL-ASPECT, Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core; SELECT-2, A Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke; RESCUE-Japan LIMIT, Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Large IscheMIc core Trial; CI, confidence interval.
Figure 4.
Figure 4.
Forest plot for endovascular thrombectomy versus medical management only for symptomatic intracranial hemorrhage. ANGEL-ASPECT, Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core; SELECT-2, A Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke; RESCUE-Japan LIMIT, Recovery by Endovascular Salvage for Cerebral Ultraacute Embolism Japan Large IscheMIc core Trial; CI, confidence interval.
See this image and copyright information in PMC

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