Background Endovascular therapy (EVT) has become the standard of care for acute ischemic stroke due to large vessel occlusion. However, outcomes vary considerably depending on embolus characteristics. Calcified cerebral emboli (CCE) pose unique challenges during EVT, including lower rates of successful recanalization, resistance to thrombus retrieval, and a potentially higher risk of complications. A systematic synthesis of EVT outcomes in patients with CCE is essential to better define their prognostic implications and guide individualized stroke management. Objective To systematically review and synthesize available evidence on clinical and angiographic outcomes following EVT in patients with acute ischemic stroke caused by calcified cerebral emboli. Methods A systematic literature search identified studies reporting EVT outcomes in patients with CCE. Data were extracted on recanalization success, thrombus resolution, intracranial hemorrhage, and modified Rankin Scale outcomes at follow‐up. Meta‐analytic pooling was performed where possible, and forest plots were generated to summarize findings. Between‐study heterogeneity was explored descriptively. Results Five studies encompassing 138 patients were included. Successful reperfusion (mTICI ≥2b) was achieved in 44‐58% of cases, while functional independence (mRS ≤2 MC1 at 90 days) was reported in 26‐29% of patients. Hemorrhagic complications ranged from 0% to 23%, and 90‐day mortality was as high as 56% in some cohorts. Thrombus resolution was inconsistently reported, with limited comparative data available. Conclusion Patients with calcified cerebral emboli represent a high‐risk subgroup of acute ischemic stroke, characterized by modest rates of recanalization and functional recovery alongside substantial mortality and procedural challenges. While EVT remains the only viable therapeutic option, current outcomes are less favorable than in broader EVT populations. Importantly, treatment does not appear to significantly increase the risk of hemorrhage, underscoring its role as a necessary intervention in this context. These findings underscore the urgent need for device innovations, standardized outcome reporting, and prospective studies specifically focused on CCE to refine patient selection and optimize interventional strategies.
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