Long-term outcomes of endovascular thrombectomy vs. medical care in patients with large ischemic stroke: a systematic review and meta-analysis of randomized controlled trials

Background Several randomized controlled trials (RCTs) have shown endovascular thrombectomy (EVT) to be superior to standard medical care (MC) for anterior circulation large vessel occlusion (LVO) -related large ischemic infarcts at the 90-day follow-up, but long-term (≥90 days) safety and effectiveness evidence is lacking. Objectives This meta-analysis used high-quality RCTs (1-year follow-up) to assess EVT’s clinical benefits in this patient group and compare short- vs. long-term prognostic changes. Search methods Literature searches were conducted in PubMed/MEDLINE, Scopus, and Web of Science from their inception to 28 September 2025 for RCTs comparing EVT and MC in acute anterior circulation ischemic stroke (AIS) with large ischemic infarcts. Study quality was evaluated using the Cochrane risk of bias tool. Selection criteria These included RCTs enrolled patients with confirmed anterior circulation LVO and low Alberta Stroke Program Early CT Score ASPECTS ≤ 5, compared EVT and MC, and reported long-term outcome data. Data collection and analysis A meta-analysis of long-term functional/safety outcomes was performed; subgroup analyses were performed based on onset time, ASPECTS, and imaging screening methods, along with leave-one-out sensitivity analysis. Results Baseline characteristics were balanced between the groups, and all included RCTs were high-quality. At long-term follow-up (90 days to 12 months), EVT significantly improved functional excellence modified Rankin Scale 0–1; risk ratio (RR) = 3. 84, 95% confidence interval (CI) = 2. 35–6. 28; p 0. 001, functional independence (modified Rankin Scale 0–2; RR = 3. 13, 95%CI = 2. 01–4. 86; p 0. 001), and independent ambulation (modified Rankin Scale 0–3; RR = 2. 01, 95%CI = 1. 52–2. 67; p 0. 001) in patients with anterior circulation large ischemic infarcts; mortality was not significantly different between groups (RR = 0. 90, 95%CI = 0. 78–1. 05; p = 0. 19). EVT also reduced the risk of death or dependency (modified Rankin Scale 4–6; RR = 0. 78, 95%CI = 0. 73–0. 84; p 0. 001). Long-term follow-up revealed more significant prognostic improvements with EVT compared with short-term follow-up. Conclusion In AIS patients with anterior circulation LVO-related large ischemic infarcts, EVT plus MC yielded statistically significant long-term functional improvements compared with MC alone. EVT’s benefits were amplified with longer follow-up and were more pronounced in patients with shorter onset time and smaller infarct volume. Systmatic review registraion https: //www. crd. york. ac. uk/prospero/displayᵣecord. php? ID=CRD420251144703, CRD420251144703.