Predictors of functional outcome after endovascular thrombectomy in patients with large ischemic core based on DWI-ASPECTS.

BackgroundThe available evidence supporting the use of endovascular thrombectomy (EVT) in acute ischemic stroke patients with large core has increased with the recent release of the Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Efficacy and Safety of Thrombectomy In Stroke with Extended Lesion and Extended Time Window (TENSION), and Large Stroke Therapy Evaluation (LASTE) trials, providing critical information on additional subgroups not included in initial trials. We aimed to study the efficacy and safety of EVT in patients with acute ischemic stroke with large core and stratify by several subgroups including core infarct at presentation, using a comprehensive meta‐analysis of aggregate data.MethodsWe executed a systematic search to identify randomized controlled trials that compared EVT to medical management (MM) for the treatment of patients with acute ischemic stroke with large core, defined as Alberta Stroke Program Early CT [Computed Tomography] Score ≤5 on noncontrast CT and/or estimated ischemic core ≥50 mL on CT‐perfusion/MR diffusion. The primary outcome was the shift analysis in the 90‐day modified Rankin scale (mRS) score. Secondary outcomes included functional independence (mRS score 0–2), independent ambulation (mRS score 0–3), 90‐day mortality, and symptomatic intracranial hemorrhage. Pooled odds ratios were calculated for shift mRS score through the random‐effects meta‐analyses, and risk ratios (RRs) were used for the other outcomes, comparing EVT with MM alone.ResultsOut of 3402 titles and abstracts screened, 6 randomized controlled trials with 1886 patients were included. The EVT group had a higher shift toward a lower mRS than MM alone (odds ratio [OR], 1.49 [95% CI, 1.24–1.79]). Furthermore, the use of EVT was associated with higher rates of functional independence (19.5% versus 7.5%, RR, 2.49 [95% CI, 1.92–3.24]), independent ambulation (36.5% versus 19.9%, RR, 1.91 [95% CI, 1.51–2.43]), and symptomatic intracranial hemorrhage (5.5% versus 3.2%, RR, 1.73 [95% CI, 1.01–2.95]) compared with MM. There was no difference between the 2 groups regarding mortality (31.5% versus 36.8%, RR, 0.86 [95% CI, 0.72–1.02]). Importantly, EVT was consistently associated with a shift toward a lower mRS score in both Alberta Stroke Program Early CT Score 3–5 (OR, 1.60 [95% CI, 1.10–2.32]) and Alberta Stroke Program Early CT Score 0–2 (OR, 1.45 [95% CI, 1.17–1.80]) when compared with MM alone.ConclusionOur results confirm the efficacy of EVT for acute ischemic stroke with large core and suggest a consistent benefit across all Alberta Stroke Program Early CT Score categories. These results represent an important shift in the current large vessel occlusion selection paradigm that currently considers core as an effect modifier for EVT selection.

Background: Endovascular thrombectomy (EVT) efficacy and safety is not established in patients with large core. We evaluated the clinical and radiologic outcomes following EVT in acute strokes with large ischemic core lesions defined by CT ASPECTS and/or CTP. Methods: From a multicenter prospective cohort study of imaging selection for thrombectomy (SELECT), patients with large ischemic core on CTP (rCBF< 30%) >50 ml and/or ASPECT≤5 up to 24 hrs from last known well were identified at 9 U.S centers. All patients received a baseline CT and CTP with automated ischemic core determination by RAPID. A blinded core lab adjudicated all images. The primary outcome was 90 day mRS 0-2. Safety outcomes were sICH and mortality. Outcomes of EVT patients were compared to those who received medical management (MM) only. Results: Of 445 enrolled, 106 had large core on either CT or CTP: 71 ASPECTS≤5 (EVT 37, MM 34) and 75 CTP core >50 ml (EVT 40, MM 35), 40 on both CT and CTP. Median (IQR) age 66 yr, NIHSS 20 (16-23), time to puncture 224 min (range 69-832), ASPECTS 5 (4-6) and CTP core 72 ml (41-96). Baseline characteristics were similar in EVT vs. MM patients in both CT and CTP definition groups. The EVT group had better mRS 0-2 rates as compared to MM (32 % vs 14%), aOR: 2.9 (95% CI: 1.0-7.9, p=0.041) and a favorable mRS shift on ordinal analysis aOR: 2.0 (95% CI 1.0-4.1, p=0.049), smaller final infarct volume 96 (49-196) vs 175 (127-225) ml, p=0.02, and less infarct growth 44 (0.7-107.6) vs 83 (61-133) ml, p=0.03 with similar mortality 29% EVT, 42% MM, p=0.16 and sICH 13% EVT, 7% MM, p=0.3. EVT patients were more likely to achieve mRS 0-2 if treated early (0-6) vs late (>6-24 hrs) for both CTP defined (27% vs 0%) and CT defined large core (44% vs. 18%). The good outcome declined by 20% for each hr of treatment delay (Fig 1). Conclusion: EVT may be effective and safe for patients with a large core, especially if treated early. RCTs are needed.

To establish whether collateral circulation was associated with functional outcome in stroke patients with large infarct size (Alberta Stroke Program Early CT Score [ASPECTS] ≤ 5) undergoing endovascular thrombectomy (EVT) METHODS: Consecutive patients with acute ischemic stroke due to large-vessel occlusion in the anterior circulation and an ASPECTS of ≤ 5 were analyzed. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)-ASPECTS rating system (score ranging from 0 [no FVH] to 7 [FVHs abutting all ASPECTS cortical areas]) by two independent neuroradiologists. Good functional outcome was defined by modified Rankin Scale (mRS) score of 0 to 3 at 3 months. We determined the association between FVH score and clinical outcome using multivariable regression analyses. A total of 139 patients (age, 63.1 ± 20.8 years; men, 51.8%) admitted between March 2012 and December 2017 were included. Good functional outcome (mRS 0-3) was observed in 65 (46.8%) patients, functional independence (mRS 0-2) was achieved in 43 (30.9%) patients, and 33 (23.7%) patients died at 90 days. The median FVH score was 4 (IQR, 3-5). FVH score was independently correlated with good outcome (adjusted OR = 1.41 [95% CI, 1.03-1.92]; p = 0.03 per 1-point increase). In stroke patients with large-volume infarcts, good collaterals as measured by the FVH-ASPECTS rating system are associated with improved outcomes and may help select patients for reperfusion therapy. • Endovascular thrombectomy can allow almost 1 in 2 patients with large infarct cores to achieve good functional outcome (modified Rankin Scale [mRS] of 0-3) and 1 in 3 patients to regain functional independence (mRS 0-2) at 3 months. • The extent of FVH score (as reflected by FLAIR vascular hyperintensity [FVH]-Alberta Stroke Program Early CT Score [ASPECTS] values) is associated with functional outcome at 3 months in this patient group.

The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6. A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting. The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well. This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.

BackgroundIt is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts.MethodsIn the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as...

Introduction: Despite the efficacy and safety of endovascular treatment (EVT) demonstrated in many large-core randomized controlled trials, up to half of the patients experience very poor outcomes, suggesting a significant number of futile treatments. We aimed to identify predictors of very poor 30-day outcomes (mRS 5-6) after endovascular thrombectomy in patients with large infarct. Methods: We conducted a prospective, multicenter, observational study in Vietnam involving four comprehensive stroke centers, screening all consecutive patients who underwent EVT within 24 hours of symptom onset from August 2023 to August 2024. Large cores were defined by an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5 on non-contrast CT or DWI-MRI and were assessed by two ASPECTS-certified stroke neurologists, with disagreements resolved by a senior reader. Risk factors were analyzed using multivariable logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with very poor outcomes defined as a mRS score of 5-6 at 30-day follow-up. The study adheres to STROBE criteria and is registered as NCT06016348. Results: Of the 1,910 patients screened, a total of 361 (18.9%) were included, with a median age of 64.0 years (55.0-70.0) and a median ASPECTS of 4.0 (4.0-5.0). Of these, 145 patients (40.2%) had a mRS of 5-6 at 30-day follow-up. In multivariable analysis, pretreatment predictors included age (aOR 1.06, 95% CI: 1.04-1.08, p &lt;0.0001), a history of atrial fibrillation (aOR 2.65, 95% CI: 1.31-5.47, p=0.007), higher baseline NIHSS (aOR 1.06, 95% CI: 1.01-1.11, p=0.02), anterior cerebral artery (ACA) lesion (aOR 2.72, 95% CI: 1.12-6.82, p=0.03), and higher glucose levels (mmol/dL) (aOR 1.03, 95% CI: 1.01-1.08, p=0.02) and lower ASPECTS (aOR 1.36, 95% CI: 1.008-1.85, p=0.04). The multivariable model demonstrated strong predictive accuracy, with an area under the receiver operating characteristic (ROC) curve of 0.789. Conclusions: This study demonstrates that advanced age, higher NIHSS scores, a history of atrial fibrillation, pre-operative glucose levels, ACA lesions, and lower ASPECTS are predictors of very poor outcomes in patients with large ischemic core thrombectomy, which may inform treatment decisions of EVT.

The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge. To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone. This prespecified analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score <6) or CT perfusion scanning (a volume with a relative cerebral blood flow <30% of ≥50 cm3) were included in analyses. Endovascular thrombectomy with medical management (MM) or MM only. Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening). A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome. Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed.

Endovascular thrombectomy (EVT) has demonstrated benefits over standard medical care (MC) in randomized controlled trials (RCTs) for patients with large vessel occlusion (LVO) and large infarct territory at 90 days. However, conflicting evidence exists regarding long-term safety and efficacy of EVT in these populations. To evaluate the clinical benefits of EVT in patients with large-core infarction through meta-analysis of high-quality RCT evidence with up to one-year follow-up. PubMed/MEDLINE, Web of Science, and Scopus databases. RCTs involving patients with confirmed LVO and Alberta Stroke Program Early CT Score (Alberta Stroke Program Early CT Score [ASPECTS]) of ≤5, comparing EVT plus MC versus MC alone, with long-term outcome data. Meta-analysis of long-term functional and safety outcomes with subgroup analysis comparing long-term (≤1 year) versus short-term (≤90 days) data on functional outcomes, imaging modalities, and presentation window. Leave-one-out sensitivity analysis was performed to resolve heterogeneity. Four RCTs comprising 1229 patients (49% female) were included. EVT demonstrated significant superiority over MC in functional independence (modified Rankin Scale [mRS] 0-2) (RR 3.91, 95% CI 2.7-5.66; P<0.001), mortality (RR 0.84, 95% CI 0.75-0.95; P = 0.005), overall survival (mRS0-5) (RR 1.17, 95% CI 1.05-1.31; P = 0.005), and quality of life (SMD 0.55, 95% CI 0.32-0.8; P<0.001) with up to one-year follow-up. No significant differences in complication rates were observed except for higher extra-cerebral thromboembolic events in the EVT group (RR 7.94, 95% CI 1.01-62.2; P = 0.048). Study limited to RCT data with potential variations in thrombectomy techniques and patient selection criteria across trials. In patients with ischemic stroke due to LVO with established large core infarct, EVT plus MC showed significant long-term benefits in functional outcomes, survival, and quality of life compared to MC alone.

BackgroundThe benefit of mechanical thrombectomy (MT) in ischemic stroke patients with ASPECTS<6 is still uncertain. ASPECTS rating is based on the presence of relative hypoattenuation, however the degree of hypoattenuation,...

BackgroundThe incidence of intracerebral hemorrhage (ICH) and its effect on the outcomes after endovascular thrombectomy (EVT) for patients with large core infarcts have not been well-characterized.MethodsSELECT2 trial follow-up imaging was...

Although previous trials have established the efficacy and safety of endovascular thrombectomy (EVT) in large ischemic core strokes, most of them excluded patients with extracranial internal carotid artery (e-ICA) occlusion. We aimed to compare outcomes in patients with e-ICA occlusion and large ischemic core infarcts treated with EVT vs medical management (MM). This was a secondary analysis of the SELECT2 trial, a randomized controlled trial conducted at 31 international sites. Adult patients with proximal intracranial anterior circulation large ischemic strokes, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3-5 on noncontrast CT or ischemic core ≥50 mL on CT-perfusion/magnetic resonance-diffusion imaging, and concomitant e-ICA occlusion were selected. The primary outcomes were the distribution of modified Rankin Scale (mRS) score at 90-day follow-up and symptomatic intracranial hemorrhage (sICH). Among 352 enrolled patients, 62 (17.6%) with e-ICA occlusions were included. Of those 62 patients, 37 received EVT (median [interquartile range (IQR)] age, 65 [58-71] years; 15 women [38.5%]) and 25 received MM (median [IQR] age, 66 [61-71] years; 7 women [28%]). ASPECTS (EVT: 5 [3-5] vs MM: 5 [4-5]) and ischemic core volume (EVT: 100 [69-134] mL vs MM: 103 [78-135] mL) were similar between groups. The successful reperfusion rate with EVT was 64.9%. Patients receiving EVT demonstrated significantly better functional outcomes (adjusted generalized odds ratio 2.51; 95% CI 1.43-4.39; p = 0.001) and a higher proportion of patients achieving 90-day independent ambulation (EVT: 37.8% vs MM: 8%; adjusted relative ratio [aRR] 4.58; 95% CI 1.18-17.79; p = 0.037) and functional independence (EVT: 21.6% vs MM: 8%; aRR 2.16; 95% CI 0.53-8.83; p = 0.285). Furthermore, no heterogeneity of EVT benefit was observed by the presence or absence of e-ICA occlusion (p-interaction = 0.248). There were no sICH or parenchymal hemorrhage type 2 events in either group, and mortality was similar in the 2 groups (aRR 0.75; 95% CI 0.39-1.45; p = 0.388). Among patients with e-ICA occlusions and large ischemic core stroke, EVT was associated with better functional outcomes without significant safety concerns when compared with MM. Our findings suggest that EVT in these patients is beneficial, while the optimal treatment of the extracranial carotid occlusion remains unclear. Name of the trial: SELECT2 trial. Registration number: ClinicalTrials.gov Identifier: NCT03876457. Date of registration submission: August 3, 2019. Date of first patient enrollment: November 10, 2019. This study provides Class II evidence that for patients with large core acute ischemic stroke and concomitant e-ICA occlusion, EVT is associated with better functional outcome at 90 days compared with MM alone.

PurposeRandomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3–5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0–2 remain scarce.MethodsWe conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0–2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method.ResultsLiterature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0–2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29–2.04, P < 0.001).ConclusionThis meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0–2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0–2.Graphic abstract

The optimal management of acute ischemic stroke (AIS) patients with large vessel occlusion and large ischemic core is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared with best medical treatment (BMT) for AIS through a study-level meta-analysis and meta-regression of 6 randomized controlled trials (RCTs). PubMed, Embase, and the Cochrane databases were searched from January 1, 1980, to June 30, 2024. We limited search results to RCTs which compared EVT vs BMT among large-core AIS. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was used for abstracting and assessing data quality and validity. The risk ratio (RR) with 95% CI was used to measure the association of EVT vs BMT with outcomes. Univariable meta-regression analyses were conducted to evaluate possible moderating effects of onset to randomization time (OTR) on outcomes when comparing EVT with BMT. The primary outcome was the 90-day ordinal modified Rankin Scale (mRS). Secondary outcomes were independent ambulation (mRS 0-3) at 90 days, and symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Six RCTs comprising 1,887 patients with large core AIS were included. Pooled results showed that EVT compared with BMT was associated with improved mRS score at 90 days (generalized OR, 1.6, 95% CI 1.4-1.8) and higher odds of independent ambulation (RR 1.9; 95% CI 1.5-2.5). Although the risk of sICH was higher in the EVT group (RR 1.7; 95% CI 1.1-2.7), there was a reduction in mortality in the EVT group (RR 0.9; 95% CI 0.8-1.0). Meta-regression showed that the benefit of EVT decreased with the extension of OTR (mRS 0-3, regression slope, -0.11, 95% CI -0.12 to -0.10; mRS 0-2, regression slope, -0.15, 95% CI -0.16 to -0.14). For patients with Alberta Stroke Program Early CT Score (ASPECTS) 0-2, EVT was associated with increased 90-day mRS 0-3 (RR 2.1, 95% CI 1.4-3.3) and mRS 0-2 (RR 2.8, 95% CI 1.2-6.7). EVT improved clinical outcomes among patients with large-core AIS assessed by ASPECTS of 3-5 or volumetric methods. Patients with ASPECTS 0-2 also had benefit from EVT and require further study. These results support expansion of the routine application of EVT.

It remains unclear whether bridging therapy can achieve better neurologic outcomes than direct endovascular thrombectomy (EVT) in patients with posterior ischemic stroke. We systematically searched PubMed, EMBASE, and Cochrane databases with posterior artery occlusion treated with bridging therapy vs. EVT. Efficacy was assessed based on functional independence at 90days and successful recanalization, whereas safety was assessed by mortality, rate of symptomatic intracranial hemorrhage (sICH), and occurrence of any hemorrhage. All data were analyzed with Review Manager software v5.3 and the risk of bias was determined using the Methodological Index for Non-randomized Studies. We included 17 studies with a total of 3278 patients (1211 in the bridging therapy group and 2067 in the EVT group). Patients in the bridging group had a better functional outcome at 90days, as evidenced by a higher proportion with a Modified Rankin Scale (mRS) score of 0-2 compared with the EVT group (odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.54-2.19, P < 0.01), while no difference in mRS score of 0-3 (OR = 1.18, 95% CI: 0.96-1.45, P = 0.11). Patients in the bridging therapy group also had lower 90-day mortality rate (OR = 0.75, 95% CI: 0.59-0.95, P = 0.02). There were no significant differences between groups in rates of successful recanalization (OR = 0.96, 95% CI: 0.74-1.25, P = 0.77), sICH (OR = 1.27, 95% CI: 0.86-1.89, P = 0.24), and hemorrhage (OR = 1.22, 95% CI: 0.60-2.50, P = 0.58). Among patients with posterior ischemic stroke, bridging therapy may be superior to EVT in achieving a good functional outcome and lowering the mortality without increasing the risks of hemorrhage.

Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke due to internal carotid artery (ICA) or middle cerebral artery (MCA) M1 occlusion with a small ischemic core. However, the effect of EVT on acute stroke with a large ischemic core remains unclear. This study aimed to evaluate the association of EVT plus medical care versus medical care alone with outcomes in patients with acute stroke and a large ischemic core due to ICA or MCA M1 occlusion. PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 2000 to September 25, 2024. There were no language restrictions. Randomized controlled trials (RCTs) of patients with acute stroke and a large ischemic core that compared EVT plus medical care versus medical care alone were evaluated. We computed the random-effects estimate based on the inverse variance method. Risk ratio (RR) with 95% confidence interval (CI) was used to measure outcomes of EVT plus medical care versus medical care alone. The primary outcome was functional independence, defined as modified Rankin Scale (mRS) of 0-2 at 90 days post-stroke; and the lead secondary outcome was reduced disability, defined as ordinal shift of mRS. Safety outcomes were requiring constant care or death (mRS 5-6), death, and early symptomatic intracranial hemorrhage (sICH). Grading of Recommendations Assessment, Development and Evaluations (GRADE) was used to evaluate summaries of evidence for the outcomes. We included six RCTs comprising 1870 patients (826 females [44.2%]) with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion. All patients were nondisabled before stroke. Pooled results showed that at 90 days post-stroke, EVT plus medical care, compared with medical care alone, was associated with greater functional independence (RR 2.53, 95% CI [1.95, 3.29]; p < 0.001; number needed to treat [NNT], 9, 95% CI [6,15]) and reduced disability (common odds ratio 1.63, 95% CI [1.38, 1.93]; p < 0.001; NNT, 4 [minimum possible NNT, 2; maximum possible NNT, 6]). EVT plus medical care, compared with medical care alone, was associated with a lower risk of requiring constant care or death (RR 0.74, 95% CI [0.66, 0.84]; p < 0.001; NNT, 7, 95% CI [6,11]). EVT plus medical care, compared with medical care alone, was associated with a nonsignificantly higher proportion of patients with early symptomatic intracranial hemorrhage (RR 1.65, 95% CI [1.00, 2.70]; p = 0.05). The rates of death were not significantly different between the EVT plus medical care and medical care alone groups (RR 0.86, 95% CI [0.72, 1.02]; p = 0.08). Main limitations include variability in imaging definitions of large core and inclusion of both larger moderate and large cores in the analysis. Among patients with acute stroke and a larger moderate or large ischemic core due to ICA or MCA M1 occlusion who were nondisabled before stroke, EVT plus medical care, compared with medical care alone, may be associated with improved functional independence, reduced disability, and reduced rates of severe disability or death at 90 days post-stroke. PROSPERO registration number: CRD42024514605.