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Meta-Analysis
. 2025 Feb;46(2):801-806.
doi: 10.1007/s10072-024-07781-5. Epub 2024 Sep 30.

Endovascular treatment in ischemic strokes with large infarct core: an updated systematic review and meta-analysis of randomized controlled trials

Marco Longoni  1 , Sebastiano Giacomozzi  2 , Leonardo Pantoni  3 , Simone Vidale  4
Affiliations
Meta-Analysis

Endovascular treatment in ischemic strokes with large infarct core: an updated systematic review and meta-analysis of randomized controlled trials

Marco Longoni et al. Neurol Sci. 2025 Feb.

Abstract

Background: Endovascular treatment (EVT) is recommended for acute ischemic stroke due to large-vessel occlusion (LVO) and an ASPECTs ≥ 6. Recent randomized controlled trials (RCTs) have become available on effect of EVT in patients with LVO-related large core infarct stroke (ASPECTS 0-5). We conducted a systematic review and meta-analysis of trials on patients with large core infarct treated with thrombectomy compared to best medical therapy (BMT).

Methods: The study followed PRISMA guidelines. Primary endpoint was functional independence at 90 days (modified Rankin Scale mRS < 3). Secondary endpoints were 3-month moderate disability (mRS < 4), excellent outcome (mRS < 2) and change in mRS (shift analysis). Safety outcomes were: symptomatic intracranial hemorrhage (sICH) and 3-month mortality.

Results: Seven RCTs were included with a total of 1964 patients. Functional independence was significantly more frequent in EVT vs BMT group (19.4% vs 8%; OR = 2.72, 95%CI = 2.06-3.61, pheterogeneity = 0.08; I2: 47%). Moderate outcome was also more prevalent in EVT group (OR = 2.00; 95%CI = 1.61 - 2.48, pheterogeneity = 0.17; I2: 46%) as well as excellent outcome (OR: 1.54, 95%CI = 1.07 - 2.22, pheterogeneity = 0.13; I2: 40%). Shift analysis was also significant with OR 1.59 (CI = 1.33-1.82 and p < 0.001). Finally sICH, that occurred in 68 patients, was more frequent in EVT (OR = 1.63, 95%CI = 0.99 - 2.69, pheterogeneity = 0.68; I2: 0%) while 3 m mortality was reduced in EVT (31% vs 37,1%, OR 0.76 CI = 0.62-0.92).

Conclusions: This updated pooled data show that, in LVO-stroke patients with a large core infarct, EVT plus BMT (as compared to BMT alone) increases significantly the chances of achieving a good functional outcome at 90 days and reduces the 3- month mortality despite a marginal increase in acute sICH.

Keywords: Large ischemic stroke; Mechanical thrombectomy; Meta-analysis; Randomized controlled trial.

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Conflict of interest statement

Declarations. Ethical approval: Since we conducted a pooled analysis of aggregate data (not individual) from published randomized controlled trials, patient informed consent for this study was not collected. Meta-analysis followed PRISMA guideline and study protocol was deposited with OSF ( https://doi.org/10.17605/OSF.IO/CPW97 ). Competing interests: LP received consultancy fees from Amicus and PIAM.

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