Endovascular treatment for large-core ischaemic stroke: a meta-analysis of randomised controlled clinical trials
Lina Palaiodimou, Amrou Sarraj, Apostolοs Safouris, Georgios Magoufis, Robin Lemmens, Else Charlotte Sandset, Guillaume Turc, Marios Psychogios, Georgios Tsivgoulis
Abstract
Background and purpose Current guidelines recommend endovascular treatment (EVT) for acute ischaemic stroke (AIS), due to large-vessel occlusion and an Alberta Stroke Program Early CT Score (ASPECTS) of ≥6. High-quality evidence resulting from randomised controlled clinical trials (RCTs) regarding EVT among large-core AIS has recently become available, justifying an updated meta-analysis aiming to evaluate efficacy and safety of EVT in this clinical setting. Methods We conducted a systematic review and meta-analysis including all available RCTs that compared EVT in addition to best medical treatment (BMT) versus BMT alone for large-core AIS (defined by ASPECTS 2–5 or volumetric methods). The primary outcome was reduced disability at 3 months (≥1-point reduction across all Modified Rankin Scale (mRS) grades). Secondary outcomes included independent ambulation at 3 months (mRS score 0–3), good functional outcome at 3 months (mRS score 0–2), excellent functional outcome at 3 months (mRS score 0–1), symptomatic intracranial haemorrhage (sICH) and any intracranial haemorrhage (ICH) and mortality at 3 months. The random-effects model was used. Results Four RCTs were included comprising a total of 662 patients treated with EVT vs 649 patients treated with BMT. Compared with BMT, EVT was significantly associated with reduced disability (common OR 1.70, 95% CI 1.39 to 2.07; I 2 =0%), independent ambulation (risk ratio (RR) 1.69, 95% CI 1.33 to 2.14; I 2 =39%) and good functional outcome (RR 2.33, 95% CI 1.76 to 3.10; I 2 =0%), but not with excellent functional outcome (RR 1.46, 95% CI 0.91 to 2.33; I 2 =39%) at 3 months. Although rates of sICH (RR 1.98, 95% CI 1.07 to 3.68; I 2 =0%) and any ICH (RR 2.13, 95% CI 1.70 to 2.66; I 2 =37%) were higher in the EVT group, 3-month mortality (RR 0.98, 95% CI 0.83 to 1.15; I 2 =0%) did not differ between the two groups. Conclusion EVT appears to be effective and safe and may be considered for the treatment of large-core AIS, as assessed by ASPECTS of 2–5 or volumetric methods. PROSPERO registration number CRD42022334417.