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Updated: Sep 11, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Endovascular thrombectomy for acute ischemic stroke due to medium or distal vessel occlusion: A systematic review and
Julie de Lima Loiola1, Gabriel de Almeida Monteiro2, Marianna Leite3
1Neurology Department, University of Louisville, Louisville, USA.
Introduction:
Acute ischemic stroke (AIS) due to medium-vessel occlusion (MeVO) accounts for up to 40 % of ischemic strokes. While traditionally assumed to have better outcomes than large-vessel occlusion (LVO) strokes, recent evidence suggests that MeVO often results in poor functional outcomes despite optimal medical management. The role of endovascular thrombectomy (EVT) in MeVO remains uncertain despite recent trials, due to limited high-quality evidence when considering observational studies. This systematic review and meta-analysis evaluated the efficacy and safety of EVT compared to standard medical therapy (SMT) in patients with AIS due to MeVO.
Methods:
We systematically searched PubMed, Embase, and Cochrane Central for studies comparing EVT and SMT in patients after AIS secondary to MeVO that reported at least one clinical outcome of interest, such as functional outcome, mortality, and hemorrhagic complications. We used risk ratio (RR) with 95 % confidence intervals (CIs) as the effect size measure for binary outcomes, employing a random-effects model, and RoB-2 and ROBINS-I tools for risk of bias assessment.
Results:
We included 23 studies (2 RCTs and 21 observational studies) encompassing 7100 patients. There was not significant difference between groups regarding excellent (RR 1.08; 95 % CI 0.96-1.22; p = 0.2204; I² = 65.2 %) and functional independence outcome (RR 1.04; 95 % CI 0.93-1.15; p = 0.4924; I² = 75.1 %), and mortality (RR 1.18; 95 % CI 0.97-1.43; p = 0.0937; I² = 16.6 %). Subgroup analyses showed a benefit of EVT over SMT in PCA occlusions regarding excellent functional outcome. However, EVT was associated with a significantly higher likelihood of hemorrhagic complication than SMT, such as sICH (RR 1.69; 95 % CI 1.18-2.43; p = 0.0042; I² = 39.7 %), and its subtype, SAH (RR 7.97, 95 % CI 4.78-13.30, p < 0.0001; I² = 0.0 %).
Conclusion:
The combined therapy of EVT and SMT on MeVO AIS showed similar functional status and mortality results as SMT alone. However, the use of EVT increased the risk of hemorrhagic complications (sICH and SAH). While most subgroup analyses showed no potential benefits for M2, ACA and PCA occlusions, overall randomized data remain limited. Future trials should stratify their patient population by occlusion site.
Insights
Endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) from medium-vessel occlusion (MeVO) showed similar functional outcomes and mortality compared to standard medical therapy (SMT). However, EVT significantly increased the risk of hemorrhagic complications like symptomatic intracranial hemorrhage (sICH) and subarachnoid hemorrhage (SAH).
Area of Science:
- Neurology
- Interventional Cardiology
- Neurosurgery
Background:
- Medium-vessel occlusion (MeVO) strokes constitute a significant portion of acute ischemic strokes (AIS).
- Despite optimal medical management, MeVO strokes often lead to poor functional outcomes.
- The efficacy of endovascular thrombectomy (EVT) for MeVO remains uncertain due to limited high-quality evidence.
Purpose of the Study:
- To evaluate the efficacy and safety of EVT compared to standard medical therapy (SMT) in patients with AIS due to MeVO.
- To assess functional outcomes, mortality rates, and hemorrhagic complications associated with EVT versus SMT.
Main Methods:
- Systematic literature search of PubMed, Embase, and Cochrane Central databases.
- Inclusion of 23 studies (2 RCTs, 21 observational) with 7100 patients comparing EVT and SMT for MeVO.
- Meta-analysis using random-effects models to calculate risk ratios (RR) and 95% confidence intervals (CIs).
- Risk of bias assessment using RoB-2 and ROBINS-I tools.
Main Results:
- No significant difference in excellent functional outcome (RR 1.08; 95% CI 0.96-1.22) or functional independence (RR 1.04; 95% CI 0.93-1.15) between EVT and SMT.
- No significant difference in mortality rates (RR 1.18; 95% CI 0.97-1.43).
- EVT was associated with a significantly higher risk of hemorrhagic complications, including symptomatic intracranial hemorrhage (sICH) (RR 1.69; 95% CI 1.18-2.43) and subarachnoid hemorrhage (SAH) (RR 7.97; 95% CI 4.78-13.30).
- Subgroup analysis indicated a potential benefit of EVT in PCA occlusions for excellent functional outcomes.
Conclusions:
- EVT combined with SMT for MeVO AIS showed comparable functional status and mortality to SMT alone.
- EVT use significantly increased the risk of hemorrhagic complications (sICH and SAH).
- Limited randomized data exist, and future trials should stratify patients by occlusion site.
