From Therapeutic Nihilism to Armamentarium: A Meta-analysis of Randomized Clinical Trials Assessing Safety and Efficacy of Endovascular Therapy for Acute Large Ischemic Strokes

Background: Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis.

Methods: Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI).

Results: There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48],  = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48],  < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16],  = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55],  = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41],  = 0.71).

Conclusion: This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.