Therapeutic Outcomes and Complication Rates of Image-Guided Endovascular Procedures in Cerebrovascular Disorders: An International Systematic Review and Meta-Analytic Evaluation

Abstract

Background: Cerebrovascular disorders are a major cause of death and disability worldwide. Image-guided endovascular procedures have reshaped care pathways, yet comparative data on therapeutic benefit and complications across techniques remain fragmented.

Methods: We conducted a PRISMA-aligned systematic review and meta-analytic evaluation (database inception to October 2025) of adult studies assessing mechanical thrombectomy (EVT), intra-arterial thrombolysis (IAT), aneurysm coiling, stent-assisted coiling, and flow-diversion. Primary endpoints were 90-day functional independence (modified Rankin Scale ≤2) for stroke and complete/adequate aneurysm occlusion; safety endpoints included symptomatic intracranial hemorrhage (sICH), procedure-related complications, and mortality. Random- or fixed-effects models were applied according to heterogeneity; risk of bias was appraised with Cochrane RoB 2.0 and ROBINS-I.

Results: Of 3,942 records, 23 studies met inclusion criteria. For large-vessel occlusion stroke, EVT yielded higher functional independence than best medical therapy without excess sICH (~4–5%) or mortality. In very-late presenters (>24 hours), carefully selected EVT candidates achieved functional independence ~32%, with reperfusion ~82%, sICH ~6.8%, and mortality ~27%. For ruptured and unruptured aneurysms, coiling achieved immediate occlusion ~91%, with recanalization ~21%, retreatment ~10%, and complications ~11%. Flow-diversion demonstrated ~84% complete occlusion at one year, overall complications ~17%, permanent morbidity ~4%, and mortality ~3%. Adjunct IAT after EVT was associated with higher odds of excellent outcomes without a significant rise in sICH. Heterogeneity was generally low moderate; sensitivity analyses were directionally consistent.

Conclusions: Image-guided endovascular therapy offers robust efficacy with acceptable safety across cerebrovascular indications. EVT remains standard for large-vessel stroke, while coiling and flow-diversion provide complementary aneurysm exclusion. Standardized reporting, long-term surveillance, and equitable global access should guide future practice and policy.