Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE—There is clinical equipoise about the use of advanced imaging for selecting acute ischemic stroke patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time-independent prognostic factor. METHODS—We performed a systematic review and meta-analysis of available randomized clinical trials to evaluate the impact of patient selection with advanced neuroimaging on the 3-month(1) functional independence (modified Rankin Scale score, 0–2), (2) favorable functional outcome (modified Rankin Scale scores, 0–1), (3) all-cause mortality, and (4) functional improvement (assessed with ordinal analysis of the modified Rankin Scale-scores). We compared patients with perfusion imaging documented penumbra to patients who did not have documented penumbra or perfusion imaging. RESULTS—Among the 10 eligible randomized clinical trials (2227 total patients, mean age67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month functional independence (odds ratio [OR], 3.79; 95% CI, 2.71–5.28 versus OR, 1.89; 95% CI, 1.52–2.35; P for subgroup differences