Comparison of Balloon Guide Catheters and Standard Guide Catheters for Acute Ischemic Stroke: An Updated Systematic Review and Meta-analysis

To update our 2021 systematic review and meta-analysis which reported that balloon guide catheters (BGC) are associated with superior clinical and angiographic outcomes compared to standard guide catheters for treatment of acute ischemic stroke (AIS). We conducted a systematic review of seven electronic databases to identify literature published between January 2010 to September 2023 reporting BGC versus non-BGC approaches. Primary outcomes were final modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b, first-pass effect (FPE; mTICI ≥2c on first pass), and modified Rankin Scale (mRS) 0-2 at 90 days. Risk of bias was assessed using the Newcastle Ottawa Scale. A separate random effects model was fit for each outcome. Subgroup analyses by first-line approach were conducted, with a separate random effects model on each subgroup. Twenty-four studies comprising 8,583 patients were included (4,948 BGC; 3,635 non-BGC; 1,561 BGC+Stent-retriever; 1,297 non-BGC+Stent-retriever). Nine studies had low-risk of bias, 3 were moderate-risk, and 12 were high-risk. Patients treated with BGCs had higher odds of achieving mTICI 2b/3, FPE mTICI 2c/3, and mRS 0-2 at 90 days (p<0.001). BGC+Stent-retriever was associated with higher odds of mTICI≥2b, 90-day mRS 0-2, and reduced odds of 90-day mortality compared to non-BGC+Stent-retrievers. The number needed to treat to achieve one additional successful recanalization is 17. The main limitation was the absence of randomized trials. These findings corroborate our previous results suggesting that MT using BGCs is associated with better safety and effectiveness outcomes for AIS, especially BGC+Stent-retrievers.