Mechanical thrombectomy strategies for large vessel acute ischemic stroke: evidence from a systematic review and network meta-analysis

Background Stent retriever (SR), contact aspiration (CA), and combined treatment are vital mechanical thrombectomy (MT) techniques for acute ischemic stroke (AIS) patients. Aim This study aimed to compare and rank these three MT strategies for AIS caused by large vessel occlusion using a Frequentist network meta-analysis (NMA). Methods A systematic review and Frequentist NMA following PRISMA guidelines were conducted. Relevant randomized controlled trials (RCTs) and observational studies were identified from electronic databases from inception to March 2025. Random effect models were used to estimate odds ratios (ORs) and mean differences with 95% confidence interval (CI). Results A total of 55 studies was included in the current NMA study. CA showed significantly higher modified thrombolysis in cerebral infarction (mTICI) 2c/3 scores at the end of the procedure (OR = 1.99, 95% CI [1.04, 3.81]), higher favorable modified Rankin Scale (mRS 0–2) at 3 months (OR = 1.28, 95% CI [1.03, 1.58]), and fewer adverse events (OR = 0.70, 95% CI [0.50, 0.98]) compared to combined approach. No significant differences among groups regarding National Institute of Health Stroke Scale, symptomatic intracerebral hemorrhage, and all-cause mortality. Conclusions The CA group demonstrated superior outcomes in mTICI 2c/3 scores, mRS 0–2 and adverse event rates. However, no significant differences were found between CA, SR, or combined approaches for other outcomes. These findings can guide clinicians in selecting appropriate thrombectomy strategies for AIS patients.