Endovascular therapy versus best medical treatment in pediatric acute ischemic stroke: A systematic review and meta-analysis

Purpose This systematic review and meta-analysis evaluates endovascular therapy (EVT) versus best medical treatment (BMT) in pediatric acute ischemic stroke (AIS) due to large-vessel occlusion. Methods Systematic searches were conducted across PubMed, Cochrane, and Embase, inception July-2025. Comparative studies of EVT versus BMT in pediatric AIS were included. Efficacy outcomes assessed were Modified Rankin Scale (mRS) 0–2, mRS 0–1 and Pediatric Stroke Outcome Measure (PSOM). Safety outcomes included mortality, symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (aICH), hospital stay length and need for craniectomy. Results 10 studies ( n = 20,083) were included. In the primary analysis restricted to confirmed large-vessel occlusion (LVO), EVT was associated with significantly higher odds of achieving a good functional outcome (mRS 0–2: OR 2.08; 95% CI 1.07–4.03) and showed no significant difference in all-cause mortality (OR 2.01; 95% CI 0.34–12.01) compared to BMT. In the all-comers analysis, EVT was associated with higher all-cause mortality (OR 3.00; 95% CI 2.23–4.02) and increased risk of aICH (OR 3.12; 95% CI 1.78–5.47); however, these signals were heavily confounded by baseline stroke severity. Conclusion When restricted to confirmed LVO, EVT demonstrates a potential functional benefit over BMT in pediatric AIS. The increased risks of aICH and mortality observed in broader analyses are likely confounded by indication, reflecting the selection of the most severe cases for intervention. Based on GRADE assessments, the certainty of evidence remains very low, highlighting the critical need for prospective studies incorporating standardized reperfusion metrics.