Endovascular Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion with Large Ischemic Core: A Systematic Review and Meta-Analysis

Abstract

Background: Multiple trials have evaluated the benefits of endovascular thrombectomy (EVT) in patients with large-core ischemic stroke. This study aimed to determine the efficacy and safety of EVT compared with medical management (MM) alone in patients with large ischemic core infarcts. Methods: This study was registered in PROSPERO (CRD420261360129). A comprehensive search of PubMed, Web of Science, and the Cochrane Library was conducted to identify all relevant studies published up to April 2026. Effect sizes were calculated as risk ratios (RRs) using random-effects or fixed-effects models, as appropriate. Study quality was assessed using the Cochrane Risk of Bias tool and the Newcastle–Ottawa Scale. Subgroup and sensitivity analyses were performed to explore heterogeneity and evaluate outcomes across different patient populations. Outcomes assessed included excellent functional independence (mRS 0–2) and favorable functional outcome (mRS 0–3) at 3 months, mean mRS at 3 and 12 months, symptomatic intracranial hemorrhage, and all-cause mortality at 3 and 12 months. Results: Nine eligible studies (5 randomized controlled trials [RCTs] and 4 cohort studies; total sample size = 2252) were included to evaluate the comparative efficacy and safety of EVT versus MM alone in patients with acute ischemic stroke (AIS) secondary to large vessel occlusion. Our pooled analysis demonstrated a significantly higher rate of achieving a modified Rankin Scale (mRS) score of 0–2 in the EVT group compared with the MM group (RR = 2.64, 95% CI [1.79–3.90], p < 0.00001). Similarly, the likelihood of achieving an mRS score of 0–3 was significantly greater with EVT than with MM (RR = 1.78, 95% CI [1.40–2.26], p < 0.00001). The mean mRS score at 3 months was also significantly lower in the EVT group (MD = −0.58, 95% CI [−0.77 to −0.39], p < 0.00001). Safety outcomes were comparable between groups, with no significant differences in the rates of symptomatic intracranial hemorrhage (sICH) (RR = 1.36, 95% CI [0.88–2.11], p = 0.17) or mortality (RR = 0.96, 95% CI [0.65, 1.42], p = 0.84, I2 = 75%). Conclusions: Our findings suggest that EVT is associated with improved functional outcomes compared with MM alone, particularly in evidence derived from RCTs, while maintaining an acceptable safety profile. Further high-quality RCTs are warranted to strengthen the evidence base and validate these findings.