Endovascular Thrombectomy Versus Standard Medical Treatment Alone in Patients With Acute Ischemic Stroke With Large Infarct (ASPECTS ≤ 5): a Systematic Review and Meta-Analysis of Randomized Controlled Trials
Anthony Hong1, Ocilio Ribeiro Gonçalves2, Ana Santos1, Matheus Felipe Henriques Brandão3, Gabriel de Almeida Monteiro4, Luma Rodrigues5, Arlindo Bispo da Silva Júnior2, Gabriel Simoni6, Kairo Igor Freitas de Aquino7, Pedro Barreto Pires Bezerra Filho8, Marina Vilardo9, Marcio Yuri Ferreira10, Savio Batista11, Victor Gonçalves Soares12, Vitor Ribeiro Gonçalves13, Kelson James Almeida2
1University of Costa Rica, 2Federal University of Piaui, 3Nova Esperança Faculty of Medicine, 4Federal University of Ceará, 5Federal University of Piauí, 6Centro Universitário de Várzea Grande, 7Uninovafapi Universitary Center, 8Universitary Center of João Pessoa, 9Catholic University of Brasilia, 10Lenox Hill Hospital/Northwell Health, 11UFRJ, 12Federal University of the Jequitinhonha and Mucuri Valleys, 13Department of Neurosurgery, Santa Casa de Belo Horizonte
Objective:
To compare the efficacy, risk of bleeding, and risk of mortality between endovascular thrombectomy (EVT) and standard medical treatment (SMT) alone in patients with acute ischaemic stroke (AIS) with moderate to low ASPECTS.
Background:
Evidence suggests increased benefits of EVT in AIS with large infarct in comparison with SMT alone. A previous meta-analysis evaluated the impact of EVT in AIS with extreme low ASPECTS (≤2). However, there is no current comparative meta-analysis evaluating the effect of EVT in AIS with moderate to low ASPECTS (≤5).
Design/Methods:
Medline, Embase, and Cochrane databases were systematically searched until June 2024, assessing randomized controlled trials (RCTs) comparing EVT and SMT alone in patients with AIS with ASPECTS ≤5. Primary outcomes included successful reperfusion and modified Rankin scale (mRS). Secondary outcomes included death from any cause, intracranial hemorrhage, and EQ-5D-5L Utility Index. R Studio was used for statistical analysis.
Results:
Five RCTs were included in this meta-analysis, comprising 1586 patients, with 795 patients receiving EVT. Successful reperfusion was achieved in 78.65% (95% CI 73.05% - 84.24%; I² = 61%) of the patients in EVT. There was a statistically significant difference favorable to EVT regarding mRS 0-2 (RR 2.71; 95% CI 2.04 - 3.61; I² = 0%) and mRS 0-3 (RR 2.04; 95% CI 1.52 - 2.74; I² = 62%). In the EVT group, death from any cause was lower (RR 0.82; 95% CI 0.68 - 0.99; I² = 43%), intracranial hemorrhage was higher (RR 1.65; 95% CI 1.04 - 2.62; I² = 0%), and the EQ-5D-5L Utility Index was higher (MD 0.20; 95% CI 0.12 - 0.28; I² = 0%).
Conclusions:
EVT is an effective treatment for large infarctions, showing better neurological functional outcomes and reduced mortality compared to SMT alone. However, it shows a higher risk of intracranial hemorrhage, which is an important aspect to take into consideration.
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