Endovascular Thrombectomy for Acute Stroke with Large Ischemic Core: A Meta-analysis of Randomized Clinical Trials

ABSTRACT Background Endovascular thrombectomy (EVT) is standard treatment for an acute ischemic stroke due to large-vessel occlusions (AIS-LVO) with a small ischemic core, but the effect of EVT on AIS-LVO with a large ischemic core remains unclear. The objective was to assess the benefit and safety of EVT for AIS-LVO with large ischemic cores. Methods and Finding PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1 2000 to September 25 2025. Randomized clinical trials (RCTs) of patients with AIS-LVO and large ischemic cores that compared EVT plus medical care vs. medical care alone were evaluated. Risk ratio (RR) with 95% CI was used to measure outcomes of EVT vs. medical care alone. Primary outcome was functional independence, defined as modified Rankin Scale (mRS) of 0 to 2 at 90 days; and lead secondary outcome was reduced disability, defined as ordinal shift of mRS. Safety outcomes were requiring constant care or death (mRS 5 to 6), death, and early symptomatic intracranial hemorrhage (sICH). We included 6 RCTs comprising 1870 patients (women 826 44.2%) with AIS-LVO. Pooled results showed that at 90 days, EVT vs. medical care alone was associated with greater functional independence (RR 2.53, 95% CI, 1.95-3.29; number needed to treat NNT, 9) and reduced disability (common odds ratio 1.63, 95% CI 1.38-1.93; NNT, 4). EVT vs. medical care alone was associated with a lower risk of requring constant care or death (RR 0.74, 95% CI 0.66 to 0.84; NNT, 7). The rates of death and early sICH were not significantly different between the EVT and medical care alone groups. Conclusions EVT combined with medical care compared with medical care alone may be associated with improved functional outcomes and reduced severe disability or death at 90 days for acute stroke with large ischemic cores. PROSPERO registration number CRD42024514605