Endovascular thrombectomy for large-core stroke: a meta-analysis with trial sequential analysis

Abstract

Background

Recent studies have reported that endovascular thrombectomy (ET) may improve neurological outcomes in large-core stroke.

Objective

We performed a systematic review and meta-analysis to compare the pooled efficacy and safety of ET and of the best medical treatment among patients with large-core stroke.

Methods

We searched the PubMed/MEDLINE, Scopus, and Cochrane databases from inception to November 2023. The inclusion criteria were randomized controlled trials (RCTs) comparing ET and the best medical treatment available among patients with large-core stroke (Alberta Stroke Program Early Computed Tomography Score [ASPECTS] < 6 or ischemic core > 50 mL on perfusion imaging) within 24 hours of symptom onset.

Results

We included 6 RTCs comprising 1,887 patients (ET group: n = 945). Endovascular thrombectomy was associated with good neurological outcomes (odds ratio [OR]: 2.92; 95% confidence interval [95%CI]: 2.17–3.93), or independent walking (OR: 2.22; 95%CI: 1.72–2.86). Trial sequential analysis confirmed a robust statistical significance for good neurological outcomes favoring ET. Endovascular thrombectomy was associated with higher risks of developing intracranial bleeding (OR: 2.65; 95%CI: 1.35–5.22) and symptomatic intracranial bleeding (OR: 1.83; 95%CI: 1.14–2.94). There were no differences between the groups regarding mortality or decompressive craniectomy. Patients submitted to non-contrast computed tomography (CT) with CT angiography (CTA) scans were analyzed separately and showed good neurological outcomes, comparable to those of the patients submitted to other imaging modalities (OR: 3.24; 95%CI: 1.52–6.92).

Conclusion

Endovascular thrombectomy was associated with good neurological outcomes and independent walking in patients with large-core acute ischemic stroke. However, it was also associated with an increased risk of developing intracranial bleeding. Non-contrast head CT with CTA scans may be appropriate for screening patients to undergo ET.

Keywords

Diagnostic Imaging - Ischemic Stroke - Thrombectomy - Mechanical Thrombolysis - Patient Outcome Assessment

Authors' Contributions

Conceptualization: MARS; Data curation: MARS, PM; Formal Analysis: MARS, PM; Investigation: MARS, PM, ALBS, LN, TPM, LLX, MCD; Methodology: MARS, PM, ALBS, LN, TPM, LLX, MCD; Project administration: MARS; Resources: MARS; Software: MARS; Supervision: LN, LLX, MCD; Validation: MARS, PM, ALBS, LN, TPM, LLX, MCD; Visualization: MARS; Writing – original draft: MARS; Writing – review & editing: MARS, PM, ALBS, LN, TPM, LLX, MCD.

Editor-in-Chief: Ayrton Roberto Massaro.

Associate Editor: Diana Aguiar de Sousa.

Publikationsverlauf

Eingereicht: 05. Juli 2024

Angenommen: 30. Dezember 2024

Artikel online veröffentlicht:
13. Mai 2025

• References

• 1 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418 https://www.ahajournals.org/doi/10.1161/STR.0000000000000211 cited 2024Jan14 [Internet]
• 2 Hurford R, Sekhar A, Hughes TAT, Muir KW. Diagnosis and management of acute ischaemic stroke. Pract Neurol 2020; 20 (04) 304-316
• 3 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
• 4 Campbell BCV, Mitchell PJ, Yan B. et al; EXTEND-IA investigators. A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke 2014; 9 (01) 126-132
• 5 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
• 6 Berkhemer OA, Fransen PSS, Beumer D. et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20
• 7 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
• 8 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
• 9 Yoshimura S, Sakai N, Yamagami H. et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med 2022; 386 (14) 1303-1313
• 10 Sarraj A, Hassan AE, Abraham MG. et al; SELECT2 Investigators. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med 2023; 388 (14) 1259-1271
• 11 Huo X, Ma G, Tong X. et al; ANGEL-ASPECT Investigators. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med 2023; 388 (14) 1272-1283
• 12 Yoo AJ, Zaidat OO, Al Kasab S. et al. Intraarterial Treatment Versus No Intraarterial Treatment within 24 Hours in Patients with Ischaemic Stroke and Large Infarct on Noncontrast CT (TESLA): A Multicentre, Open-Label, Blinded-Endpoint, Randomised, Controlled, Phase 3 Trial. [ Internet ]. SSRN; 2023 [cited 2023 Dec 13]. Available from: https://www.ssrn.com/abstract=4587818.
• 13 Bendszus M, Fiehler J, Subtil F. et al; TENSION Investigators. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet 2023; 402 (10414): 1753-1763
• 14 Costalat V, Jovin TG, Albucher JF. et al; LASTE Trial Investigators. Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size. N Engl J Med 2024; 390 (18) 1677-1689
• 15 Chen H, Colasurdo M. Endovascular thrombectomy for large ischemic strokes: meta-analysis of six multicenter randomized controlled trials. J Neurointerv Surg 2025; 2023-021366
• 16 Morsi RZ, Elfil M, Ghaith HS. et al. Endovascular thrombectomy for large ischemic strokes: An updated living systematic review and meta-analysis of randomized clinical trials. J Neurol Sci 2024; 460 (Apr): 123003
• 17 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
• 18 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
• 19 Higgins JPT. Cochrane Collaboration, Ed. Cochrane handbook for systematic reviews of interventions. Second edition. Hoboken, NJ: Wiley-Blackwell; 2020. . (Cochrane book series).
• 20 Johns H, Campbell B, Turc G, Churilov L. Power Analysis for Ordinal Analyses of the Modified Rankin Scale and an Online and Downloadable Tool for Practical Use. Stroke 2023; 54 (07) 1750-1760
• 21 Thorlund K, Engstrøm J, Wetterslev J, Brok J, Imberger G, Gluud C. Trial Sequential Analysis (TSA). 2017.
• 22 De Cassai A, Tassone M, Geraldini F. et al. Explanation of trial sequential analysis: using a post-hoc analysis of meta-analyses published in Korean Journal of Anesthesiology. Korean J Anesthesiol 2021; 74 (05) 383-393
• 23 Song F. Exploring heterogeneity in meta-analysis: is the L'Abbé plot useful?. J Clin Epidemiol 1999; 52 (08) 725-730
• 24 Baujat B, Mahé C, Pignon JP, Hill C. A graphical method for exploring heterogeneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med 2002; 21 (18) 2641-2652
• 25 Yoo AJ, Berkhemer OA, Fransen PSS. et al; MR CLEAN investigators. Effect of baseline Alberta Stroke Program Early CT Score on safety and efficacy of intra-arterial treatment: a subgroup analysis of a randomised phase 3 trial (MR CLEAN). Lancet Neurol 2016; 15 (07) 685-694
• 26 Sarraj A, Abraham MG, Hassan AE. et al; SELECT2 Investigators. Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial. Lancet 2024; 403 (10428): 731-740
• 27 ACTRN12622000804785. Stroke in patients with large Ischaemic Core: assessment of Reperfusion therapy Impact on Outcome (SICARIO-LC). https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12622000804785 [Internet]. 2022 ; Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02428807/full
• 28 de Souza AC, Martins SO, Polanczyk CA. et al. Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke in Brazil: Results from the RESILIENT trial. Int J Stroke 2021; 17 (08) 17 474930211055932
• 29 Moreu M, Scarica R, Pérez-García C. et al. Mechanical thrombectomy is cost-effective versus medical management alone around Europe in patients with low ASPECTS. J Neurointerv Surg 2023; 15 (07) 629-633
• 30 Göttsche J, Flottmann F, Jank L. et al. Decompressive craniectomy in malignant MCA infarction in times of mechanical thrombectomy. Acta Neurochir (Wien) 2020; 162 (12) 3147-3152
• 31 Peng G, Huang C, Chen W. et al. Risk factors for decompressive craniectomy after endovascular treatment in acute ischemic stroke. Neurosurg Rev 2020; 43 (05) 1357-1364
• 32 Heiferman DM, Tsivgoulis G, Singh S. et al. Predictors of Decompressive Hemicraniectomy in Successfully Recanalized Patients With Anterior Circulation Emergency Large-Vessel Occlusion. SVIN 2022; 2 (05) e000252
• 33 Yamaguchi T, Mori E, Minematsu K. et al; Japan Alteplase Clinical Trial (J-ACT) Group. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37 (07) 1810-1815
• 34 Miyamoto S, Ogasawara K, Kuroda S. et al; Committee for Stroke Guideline 2021, the Japan Stroke Society. Japan Stroke Society Guideline 2021 for the Treatment of Stroke. Int J Stroke 2022; 17 (09) 1039-1049
• 35 Mehta RH, Cox M, Smith EE. et al; Get With The Guidelines-Stroke Program. Race/Ethnic differences in the risk of hemorrhagic complications among patients with ischemic stroke receiving thrombolytic therapy. Stroke 2014; 45 (08) 2263-2269
• 36 Tsai CF, Anderson N, Thomas B, Sudlow CLM. Comparing Risk Factor Profiles between Intracerebral Hemorrhage and Ischemic Stroke in Chinese and White Populations: Systematic Review and Meta-Analysis. Quinn TJ, editor. PLoS ONE. 2016; 11 (03) e0151743
• 37 Pande SD, Win MM, Khine AA. et al. Haemorrhagic transformation following ischaemic stroke: A retrospective study. Sci Rep 2020; 10 (01) 5319
• 38 Xu X, Wang D, Wang F, Norton C, Liu X, Selim M. The Risk of Hemorrhagic Transformation After Thrombolysis for Acute Ischemic Stroke in Chinese Versus North Americans: A Comparative Study. J Stroke Cerebrovasc Dis 2018; 27 (09) 2381-2387