Evaluating Thrombectomy Devices and Combination Therapies in Acute ischemic Stroke: A systematic review & Network Meta-Analysis of 201 studies

Abstract Background and Objective Mechanical Thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, the relative efficacy and safety of different MT devices remain uncertain. To evaluate and compare the safety and efficacy of different Thrombectomy devices and combination therapies in acute ischemic stroke, utilizing a network meta-analysis. Methods Patients receiving different MT devices (MERCI, TREVO, Solitaire, Penumbra, or a combination of MT devices) compared to Standard Care or Intravenous Thrombolysis (IVT), or Intra-arterial Thrombolysis (IAT) for AIS treatment. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and all-cause mortality at 90 days. Efficacy outcome were good functional recovery at 90 days (defined as a modified Rankin Scale score of 0–2) and successful recanalization (measured by a TICI score of 2b-3). Results We included 201 studies, comprising 43 RCTs and 159 cohort studies with 71,154 AIS patients. TREVO device demonstrated the highest efficacy for functional recovery (OR=3.63, 95% CrI: 2.45–5.43), followed by MT + IVT (OR=2.87, CrI: 2.30–3.59). TREVO also achieved the highest rate of successful recanalization (OR 3.35, CrI: 1.36–8.19). MERCI, Solitaire and Aspiration devices were linked to a higher risk of sICH. For all-cause mortality at 90 days, TREVO notably reduced the odds (OR=0.56, CrI: 0.37–0.86), whereas aspiration devices showed no significant difference from standard treatments. Conclusion Our findings demonstrate contemporary stent-retriever device technology as the most effective option for improving functional recovery, recanalization success, and reducing mortality in AIS patients. These results highlight the critical need for selecting the most effective and safest thrombectomy device to optimize outcomes in acute stroke care.