Comparative Efficacy of Endovascular Techniques for Acute Ischemic Stroke

Introduction Endovascular treatment (EVT) for acute ischemic stroke due to M2 segment middle cerebral artery occlusion remains technically challenging and underrepresented in randomized trials. The relative efficacy and safety of different EVT techniques, such as the stent retriever (SR), direct aspiration (DA), and combined techniques (DA+SR) in this patient population, are not well understood. We conducted a systematic review and network meta‐analysis (NMA) to compare outcomes across these techniques. Methods A systematic review and NMA were conducted following PRISMA‐NMA guidelines. We searched PubMed, Embase, Scopus, and Web of Science databases from inception through March 2025 for eligible studies comparing angiographic, functional, and safety outcomes between different EVT techniques. We performed a frequentist NMA using the “netmeta” package in R v4.4.1. Risk ratios (RR) along with 95% CIs were pooled using a random effects model. Treatment rankings were performed using surface under the cumulative ranking (SUCRA) probabilities. Network consistency was assessed using node‐splitting and Gelman‐Rubin diagnostics. Heterogeneity and consistency were evaluated using standard metrics. Results Twelve observational studies, including 2,741 patients, met the inclusion criteria. All models demonstrated good convergence with minimal inconsistency. SUCRA scores suggested potential advantages of DA+SR for achieving both successful and complete recanalization, DA for first‐pass effect and lower subarachnoid hemorrhage risk, and SR for complete recanalization and lower symptomatic intracranial hemorrhage risk. However, none of the pairwise comparisons reached statistical significance. Although SUCRA scores suggested a potential disadvantage of DA (26.6%) for achieving mRS 0‐2 at 90 days when compared to SR (61.7%) and DA+SR (61.6%), the pairwise comparison did not reveal a statistically significant difference. No significant differences were observed for other safety outcomes, including parenchymal hematomas and 90‐day mortality, across the different techniques. Conclusion This network meta‐analysis represents the largest combined dataset, demonstrating that all three techniques offer comparable efficacy and safety in treating M2 occlusions. While there are some trends to consider, these data support that neurointerventionalists may consider whichever technique is best suited for a given patient's anatomy to achieve recanalization. DA is a conservatively safe option that could save time and cost, while SR and DA+SR are viable options in many cases, especially when an SR is needed for navigating tortuosity.