Introduction: Endovascular thrombectomy with IV thrombolysis (EVT+IVT) may not be a viable treatment for a subgroup of patients with acute anterior ischemic stroke due to ineligibility (56%), failed EVT (20%), or lack EVT access (16%). While surgical revascularization with extracranial-intracranial bypass anastomosis or embolectomy may be an option for these individuals, literature is sparse and debated in this regard. This systematic review and meta-analysis aims to investigate outcomes of surgical revascularization in acute anterior ischemic stroke when EVT+IVT is not a viable treatment.
Methods: MEDLINE, PubMed, and Embase were searched. Primary outcomes were 90-day mRS≤2 and changes in NIHSS. Secondary outcomes were surgical-related complications and mortality. PROSPERO # CRD42024543076.
Results: Twenty-two included studies yielded 343 patients with a mean age of 65.4 years, from which 195 underwent bypass, 53 underwent embolectomy, and 95 received medical treatment as a control group. Controlling for the baseline characteristics, the OR of 90-day mRS≤2 was significantly higher with surgical revascularization (OR=8.54 [1.87, 38.94], p=0.006, NNT=2) and bypass (OR=11.58 [1.69, 79.12], p=0.01, NNT=2) vs the control group. Furthermore, bypass (MD=-5.95 [-8.61, -3.30], p< 0.001) and embolectomy (MD=-10.34 [-14.63, -6.05], p< 0.001) significantly decreased NIHSS postoperatively. Surgical-related complications occurred in 8 (3.2%) individuals. Furthermore, the mortality odds was similar between the surgical and control groups (RR=0.67 [0.30, 1.45], p=0.31). Multivariable logistic regression analyses demonstrated that age (OR=0.870 (0.792-0.936), p=0.009), preoperative NIHSS (OR=0.778 (0.659-0.893), p=0.001), time from stroke onset to bypass>1 week (OR=0.013 (0.002-0.442), p=0.023), and double-barrel bypass (OR=9.488 (1.341-100.36), p=0.035) were associated with 90-day mRS≤2 in the bypass group, and age (OR=0.861 (0.743-0.948), p=0.014) and preoperative NIHSS (OR=0.772 (0.608-0.916), p=0.010) were associated with 90-day mRS≤2 in the embolectomy group.
Conclusion : Surgical revascularization with bypass or embolectomy could be beneficial and safe for acute anterior ischemic stroke patients when EVT+IVT is not a viable option.
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