Journal article
Endovascular Thrombectomy Versus Best Medical Therapy for Large Vessel Occlusion Stroke Beyond 24 Hours: A Systematic Review and Meta-Analysis
Stroke (1970), Vol.56(11), pp.3127-3137
11/2025
DOI: 10.1161/STROKEAHA.125.052121
PMID: 40970285
Abstract
The benefit of endovascular thrombectomy (EVT) beyond 24 hours from last known well in acute ischemic stroke remains uncertain. Although some slow progressors may retain salvageable tissue, supporting evidence in this ultra-late window comes mainly from small observational studies.
We systematically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Central up to February 2025 for studies comparing EVT and best medical therapy in patients with acute ischemic stroke treated >24 hours from last known well. Eligible studies reported functional independence (90-day 0-2 modified Rankin Scale score), excellent clinical outcome (90-day 0-1 modified Rankin Scale score), symptomatic intracranial hemorrhage, or 90-day mortality. Pooled unadjusted and adjusted odds ratios (ORs) with 95% CIs were calculated using random-effects meta-analyses. Subgroup analyses were performed by study design, stroke severity, imaging modality, and occlusion territory. Statistical heterogeneity was assessed using the I² statistic and the Cochran
test, and the certainty of evidence (CoE) was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation approach.
Ten observational studies (3 prospective and 7 retrospective) comprising 1871 patients (EVT: 866; best medical therapy: 1009) were included. EVT was associated with significantly higher odds of functional independence (8 studies; adjusted OR, 4.62 [95% CI, 3.30-6.47];
²=0%; low CoE) and excellent clinical outcome (2 studies; adjusted OR, 5.68 [95% CI, 2.49-12.97];
²=0%; very-low CoE). EVT increased the risk of symptomatic intracranial hemorrhage (4 studies; adjusted OR, 9.54 [95% CI, 3.78-21.07];
²=0%; low CoE), but 90-day mortality did not differ significantly between groups (4 studies; adjusted OR, 0.63 [95% CI, 0.30-1.31];
²=41.2%; very-low CoE). All subgroup analyses aligned with the main findings.
Our results revealed that EVT was associated with improved functional outcomes without an increase in 90-day mortality, despite a higher symptomatic intracranial hemorrhage risk. Given the limited CoE and overall study quality, ongoing randomized trials are essential to confirm these findings and guide patient selection in the ultra-late time window.
Details
- Title: Subtitle
- Endovascular Thrombectomy Versus Best Medical Therapy for Large Vessel Occlusion Stroke Beyond 24 Hours: A Systematic Review and Meta-Analysis
- Creators
- Aaron Rodriguez-Calienes - Jackson Memorial HospitalNagheli Borjas - Facultad de Medicina Humana, Universidad San Martín de Porres, Lima, Peru (N.B.)Sai Sanikommu - University of MiamiFabian A Chavez-Ecos - Saint Aloysius Gonzaga National UniversityMartha I Vilca-Salas - Universidad Peruana Cayetano HerediaPedro B Rodrigues - University of MiamiCristian Morán-Mariños - Universidad San Ignacio de LoyolaDileep R Yavagal - University of MiamiNegar Asdaghi - University of MiamiSantiago Ortega-Gutierrez - University of Iowa Hospitals and Clinics
- Resource Type
- Journal article
- Publication Details
- Stroke (1970), Vol.56(11), pp.3127-3137
- DOI
- 10.1161/STROKEAHA.125.052121
- PMID
- 40970285
- NLM abbreviation
- Stroke
- ISSN
- 1524-4628
- eISSN
- 1524-4628
- Publisher
- LIPPINCOTT WILLIAMS & WILKINS
- Language
- English
- Electronic publication date
- 09/19/2025
- Date published
- 11/2025
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984963625502771
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