Efficacy and Safety of Endovascular Thrombectomy in Large‐Core Infarcts: A Systematic Review and Meta‐Analysis

ABSTRACT Endovascular thrombectomy (EVT) is established as standard care for acute ischemic stroke with large vessel occlusion; however, its benefit in patients with large‐core infarcts remains controversial despite recent randomized controlled trials. We performed a meta‐analysis using risk ratio analysis to provide clinically interpretable estimates of treatment effects compared to existing odds ratio‐based analyses, with comprehensive safety profiling and detailed evidence quality assessment. We included randomized controlled trials comparing EVT with medical management in patients with large‐core strokes (defined by ASPECTS ≤ 5 or core volume > 70 mL). The primary outcome was functional independence (modified Rankin Scale 0–2) at 90 days. Secondary outcomes included mortality, symptomatic intracranial hemorrhage, and successful reperfusion. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using random‐effects models, with number‐needed‐to‐treat (NNT) and number‐needed‐to‐harm (NNH) analysis. Six trials comprising 1872 patients (940 EVT, 932 medical management) were included. EVT significantly increased the likelihood of functional independence compared to medical management (RR 1.73 95% CI: 1.32–2.26, NNT = 8). There was no difference in 90‐day mortality (RR 0.99 95% CI: 0.80–1.23). EVT was associated with higher rates of symptomatic intracranial hemorrhage (RR 2.13 95% CI: 0.79–5.77, NNH = 36), with substantial heterogeneity ( I 2 = 36.4%). This meta‐analysis demonstrates that EVT improves functional outcomes in selected patients with large‐core strokes without increasing mortality, with a favorable risk–benefit profile (NNT = 8 vs. NNH = 36). Risk ratio analysis provides enhanced clinical interpretability compared to existing odds ratio‐based meta‐analyses, supporting expanding EVT eligibility criteria to include carefully selected patients with large‐core infarcts. Trial Registration The protocol for the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD420251055286)