Mechanical thrombectomy for acute ischemic stroke in the Middle East and North Africa: a systematic review and meta-analysis of clinical outcomes, treatment delays, and access to care

Introduction Mechanical thrombectomy (MT) has transformed the treatment of acute ischemic stroke caused by large-vessel occlusion. Evidence describing thrombectomy outcomes and access across the Middle East and North Africa (MENA) remains fragmented. We synthesised outcomes among thrombectomy-treated patients and separately evaluated published evidence on treatment delays, service capacity, and access across the region. Methods We conducted a systematic review with random-effects meta-analysis of aggregate study-level clinical outcomes and a separate structured narrative synthesis of health-system and access evidence from prespecified MENA countries. The clinical evidence was predominantly observational and centre-based. Primary outcomes were approximately 90-day functional independence (modified Rankin Scale [mRS] 0–2), successful reperfusion (TICI/mTICI 2b–3), 90-day mortality, and symptomatic intracranial haemorrhage (sICH). Single-arm proportions were pooled on the logit scale using restricted maximum-likelihood random-effects models with Hartung-Knapp confidence intervals. Overlapping cohorts were assessed to avoid duplicate contribution to the same outcome. Results Twenty-nine reports describing 29 distinct investigations were included. The two Jeddah investigations recruited partially overlapping patient populations and were handled using outcome-specific deduplication. Other investigations from the same institution with possible participant overlap were retained as distinct studies when they addressed separate research questions and were not double-counted within a pooled endpoint. Fourteen reports represented an estimated 2,118 unique thrombectomy-treated patients and contributed to at least one primary meta-analysis. Nine cohorts comprising 1,576 patients with evaluable 90-day follow-up yielded a pooled functional-independence rate of 58.4% (95% CI 43.8–71.6%; I²=91.9%; 95% prediction interval 19.4–89.1%). Eleven datasets comprising 1,559 patients yielded a successful-reperfusion rate of 85.8% (95% CI 78.4–91.0%; I²=84.9%). Five studies comprising 632 patients yielded a pooled 90-day mortality of 13.0% (95% CI 7.7–21.2%; I²=60.3%), and six datasets comprising 712 patients yielded a pooled sICH frequency of 7.1% (95% CI 3.0–15.6%; I²=78.4%). Separate service studies identified variation in thrombectomy availability, workforce, 24-hour coverage, transfer pathways, telestroke, and reimbursement. Conclusion Published cohorts from selected MENA thrombectomy centres demonstrate that high reperfusion rates and favourable functional outcomes are achievable among treated patients, although clinical outcomes vary substantially between cohorts. The proportion of all thrombectomy-eligible patients who accessed treatment remains unknown, and many MENA countries are not represented in the clinical evidence. Regional service studies independently identify important workforce and access limitations, but their effects on population-level treatment rates and clinical outcomes could not be quantified.