Endovascular thrombectomy for acute ischemic stroke due to medium or distal vessel occlusion: A systematic review and meta-analysis

IF 1.6 4区医学 Q3 CLINICAL NEUROLOGY

Clinical Neurology and Neurosurgery Pub Date : 2025-08-11 DOI:10.1016/j.clineuro.2025.109101

Julie de Lima Loiola , Gabriel de Almeida Monteiro , Marianna Leite , Beatriz Araújo , Giovanna Ueda , Antonio Mutarelli , Dhruvi Kalpesh Joshi , Caroline Serafim Dagostin , Thales Pardini Fagundes

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引用次数: 0

Abstract

Introduction

Acute ischemic stroke (AIS) due to medium-vessel occlusion (MeVO) accounts for up to 40 % of ischemic strokes. While traditionally assumed to have better outcomes than large-vessel occlusion (LVO) strokes, recent evidence suggests that MeVO often results in poor functional outcomes despite optimal medical management. The role of endovascular thrombectomy (EVT) in MeVO remains uncertain despite recent trials, due to limited high-quality evidence when considering observational studies. This systematic review and meta-analysis evaluated the efficacy and safety of EVT compared to standard medical therapy (SMT) in patients with AIS due to MeVO.

Methods

We systematically searched PubMed, Embase, and Cochrane Central for studies comparing EVT and SMT in patients after AIS secondary to MeVO that reported at least one clinical outcome of interest, such as functional outcome, mortality, and hemorrhagic complications. We used risk ratio (RR) with 95 % confidence intervals (CIs) as the effect size measure for binary outcomes, employing a random-effects model, and RoB-2 and ROBINS-I tools for risk of bias assessment.

Results

We included 23 studies (2 RCTs and 21 observational studies) encompassing 7100 patients. There was not significant difference between groups regarding excellent (RR 1.08; 95 % CI 0.96–1.22; p = 0.2204; I² = 65.2 %) and functional independence outcome (RR 1.04; 95 % CI 0.93–1.15; p = 0.4924; I² = 75.1 %), and mortality (RR 1.18; 95 % CI 0.97–1.43; p = 0.0937; I² = 16.6 %). Subgroup analyses showed a benefit of EVT over SMT in PCA occlusions regarding excellent functional outcome. However, EVT was associated with a significantly higher likelihood of hemorrhagic complication than SMT, such as sICH (RR 1.69; 95 % CI 1.18–2.43; p = 0.0042; I² = 39.7 %), and its subtype, SAH (RR 7.97, 95 % CI 4.78–13.30, p < 0.0001; I² = 0.0 %).

Conclusion

The combined therapy of EVT and SMT on MeVO AIS showed similar functional status and mortality results as SMT alone. However, the use of EVT increased the risk of hemorrhagic complications (sICH and SAH). While most subgroup analyses showed no potential benefits for M2, ACA and PCA occlusions, overall randomized data remain limited. Future trials should stratify their patient population by occlusion site.

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血管内取栓术治疗中端或远端血管闭塞引起的急性缺血性卒中：一项系统综述和荟萃分析

中血管闭塞（MeVO）引起的急性缺血性卒中（AIS）占缺血性卒中的40% %。虽然传统上认为MeVO比大血管闭塞（LVO）中风有更好的结果，但最近的证据表明，尽管有最佳的医疗管理，MeVO往往导致较差的功能结果。血管内取栓术（EVT）在MeVO中的作用尽管有最近的试验，但由于观察性研究的高质量证据有限，仍然不确定。本系统综述和荟萃分析评估了EVT与标准药物治疗（SMT）相比对MeVO所致AIS患者的疗效和安全性。方法：我们系统地检索了PubMed、Embase和Cochrane Central，以比较MeVO继发性AIS患者EVT和SMT的研究，这些研究报告了至少一个感兴趣的临床结果，如功能结果、死亡率和出血性并发症。我们使用95% %置信区间（ci）的风险比（RR）作为二元结果的效应大小度量，采用随机效应模型，并使用rob2和ROBINS-I工具进行偏倚风险评估。我们纳入了23项研究（2项随机对照试验和21项观察性研究），涵盖7100例患者。组间在优秀方面差异无统计学意义(RR 1.08；95 % ci 0.96-1.22；p = 0.2204;I²= 65.2 %)和功能独立性结局(RR 1.04；95 % ci 0.93-1.15；p = 0.4924;I²= 75.1 %)，死亡率(RR 1.18；95 % ci 0.97-1.43；p = 0.0937;I²= 16.6 %)。亚组分析显示，EVT优于SMT治疗PCA闭塞，具有良好的功能预后。然而，EVT发生出血并发症的可能性明显高于SMT，如siich (RR 1.69；95 % ci 1.18-2.43；p = 0.0042;I²= 39.7 %)及其亚型SAH (RR 7.97, 95 % CI 4.78-13.30, p <； 0.0001；I²= 0.0 %)。结论EVT联合SMT治疗MeVO AIS的功能状态和死亡率与单纯SMT治疗相似。然而，EVT的使用增加了出血性并发症（sICH和SAH）的风险。虽然大多数亚组分析显示M2、ACA和PCA闭塞没有潜在的益处，但总体随机数据仍然有限。未来的试验应该根据闭塞部位对患者群体进行分层。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Clinical Neurology and Neurosurgery 医学-临床神经学

CiteScore

3.70

自引率

5.30%

发文量

358

审稿时长

46 days

期刊介绍： Clinical Neurology and Neurosurgery is devoted to publishing papers and reports on the clinical aspects of neurology and neurosurgery. It is an international forum for papers of high scientific standard that are of interest to Neurologists and Neurosurgeons world-wide.