Mechanical Thrombectomy in Ischemic Stroke with a Large Infarct Core: A Meta-Analysis of Randomized Controlled Trials

Area of Science:

• Neurology
• Interventional Cardiology
• Neurosurgery

Background:

• Current guidelines recommend endovascular treatment (EVT) for acute ischemic stroke with large-vessel occlusion (LVO) and an Alberta Stroke Program Early CT Score (ASPECTS) of 6 or higher.
• Recent randomized controlled trials (RCTs) have investigated the efficacy of EVT in patients with large-core stroke (ASPECTS 0-5), a population not typically included in earlier recommendations.

Purpose of the Study:

• To conduct an updated meta-analysis evaluating the effect of EVT on functional neurological status in patients with large-core stroke and LVO.
• To synthesize evidence from recent RCTs comparing EVT plus best medical treatment (BMT) against BMT alone in this specific patient cohort.

Main Methods:

• Systematic literature search of PubMed, EMBASE, and Cochrane Central databases following PRISMA guidelines.
• Inclusion of RCTs comparing EVT versus BMT for large-core LVO stroke.
• Primary outcome: functional independence at 90 days (modified Rankin Scale [mRS] 0-2). Secondary outcomes: symptomatic intracranial hemorrhage (sICH), good functional outcome (mRS 0-3), and excellent functional outcome (mRS 0-1). Random effects meta-analysis was employed.

Main Results:

• Six RCTs comprising 1656 patients were included, all demonstrating a moderate risk of bias.
• EVT plus BMT significantly increased functional independence (OR = 2.47, 95% CI = 1.52-4.03, p < 0.001) and good functional outcome (OR = 2.20, 95% CI = 1.72-2.81, p < 0.001) compared to BMT alone.
• Rates of symptomatic intracranial hemorrhage (sICH) were marginally higher in the EVT group (OR = 1.77, 95% CI = 1.01-3.11, p = 0.04), while excellent functional outcomes (mRS 0-1) did not differ significantly.

Conclusions:

• In patients with large-core stroke and LVO, the addition of EVT to BMT significantly improves functional independence and good functional outcomes at 90 days.
• Despite a slight increase in sICH, EVT offers a substantial benefit for functional recovery in this patient population.