A Systematic Review and Meta-analysis of Randomized Controlled Trials of Endovascular Thrombectomy Compared to Best Medical Treatment for Acute Ischemic Stroke

Background Acute ischemic strokes involving occlusion of large vessels usually recanalize poorly following treatment with intravenous thrombolysis. Recent studies have shown higher recanalization and higher good outcome rates with endovascular therapy compared to best medical management alone. A systematic review and meta-analysis investigating the benefits of all randomized controlled trials (RCTs) of endovascular thrombectomy where at least 25% of patients were treated with a thrombectomy device for the treatment of acute ischemic stroke compared to intravenous thrombolysis has yet to be performed. Aims To perform a systematic review and a meta-analysis evaluating the effectiveness of endovascular thrombectomy compared with best medical care for treatment of acute ischemic stroke. Summary of review Our search identified 437 publications, from which 8 studies (totaling 2,423 patients) matched the inclusion criteria. Overall, endovascular thrombectomy was associated with improved functional outcomes (mRS 0-2) (odds ratio (OR) 1.56 (1.32-1.85), p< 0.00001). There was a tendency towards decreased mortality (OR 0.84 (0.67-1.05), p=0.12) and symptomatic intracerebral hemorrhage was not increased (OR 1.03 (0.71-1.49), p=0.88) compared to best medical management alone. The OR for a favorable functional outcome increased to 2.23 (1.77-2.81, p<0.00001) when newer generation thrombectomy devices were used in greater than 50% of the cases in each trial. Conclusions There is clear evidence for improvement in functional independence with endovascular thrombectomy compared to standard medical care suggesting that endovascular thrombectomy should be considered the standard effective treatment alongside thombolysis in eligible patients.