Mechanical Thrombectomy for Acute Ischemic Stroke in Southeast Asian Countries: A Systematic Review and Meta-analysis

Keywords

mechanical thrombectomy - acute ischemic stroke - stroke - Southeast Asia - endovascular thrombectomy

Introduction

Stroke remains a major global contributor to both mortality and long-term disability, with ischemic stroke representing the predominant subtype.[1] Mechanical thrombectomy (MT) has emerged as a transformative intervention, leading to significant improvements in results for patients experiencing acute ischemic stroke (AIS) caused by occlusion of large vessels.[1] Pivotal trials such as MR CLEAN, ESCAPE, and EXTEND-IA have established MT as the preferred therapeutic approach for appropriately selected patients, particularly within the first 6 hours and sometimes up to 12 hours post-onset.[2] However, these pivotal studies were almost exclusively conducted in Western high-income countries, limiting their direct applicability to Southeast Asian nations.

The burden of stroke is disproportionately high in Southeast Asian countries. It is estimated that up to 50% of the stroke burden in developing countries is borne by the Southeast Asian region.[3] Stroke care in Southeast Asia faces major challenges, including low public awareness, limited emergency services, and underuse of treatments such as intravenous thrombolysis (IVT) and MT. Many areas lack stroke-ready centers and neurologists, especially in rural regions. Rehabilitation is often neglected due to cost, limited trained staff, and reliance on traditional medicine.[3] Despite these constraints, several centers in Southeast Asia have begun implementing MT, often in resource-limited settings. Studies from countries such as Vietnam and Indonesia suggest that MT in these countries may still achieve acceptable recanalization and functional outcomes.[4] [5]

Although previous reviews have evaluated MT outcomes in other regions, such as Latin America and low-middle-income countries, to our knowledge, no systematic synthesis has focused specifically on the Southeast Asian region.[6] [7] A focused review is needed given regional differences in healthcare infrastructure, stroke epidemiology, and interventional capacity. This review seeks to comprehensively rate the clinical effectiveness and safety of mechanical thrombectomy in treating AIS across Southeast Asian nations, based on real-world data.

Materials and Methods

The study protocol has been registered and is publicly available through the PROSPERO database with a registration ID CRD420251001873.

Eligibility Criteria

Studies were eligible if they were observational research, such as cohort, case-control, or cross-sectional, to reflect real-world clinical outcomes, or original primary studies cited within any review identified. Eligibility criteria: Studies were required to present original data on the clinical effectiveness and safety of MT. Eligible participants included adults aged 18 years or older diagnosed with AIS, as confirmed through neuroimaging approaches such as computed tomography (CT) or magnetic resonance imaging (MRI). Research focusing solely on other stroke types, such as hemorrhagic stroke or transient ischemic attacks (TIA), was excluded. Additionally, multicenter studies lacking separate subgroup analyses specific to Southeast Asian countries were not included. The intervention evaluated was MT, administered independently or combined with IVT.

Eligible studies were required to be conducted within Southeast Asia, which encompasses nations such as Cambodia, Singapore, Vietnam, Brunei, Laos, Indonesia, Thailand, Malaysia, the Philippines, Myanmar, and Timor-Leste.

Information Sources

Relevant studies were identified through comprehensive searches of PubMed and Scopus from inception through February 2025. Supplementary strategies, such as citation tracking via the reference list screening of included articles, were also employed to capture studies not indexed in these databases.

Approach to Literature Identification, Inclusion Criteria, and Data Collection

A structured search strategy was developed using combinations of terms such as (“thrombectomy” OR “endovascular thrombectomy”) AND (“acute ischemic stroke” OR “large vessel occlusion” OR “AIS” OR “LVO”) AND country-specific identifiers (“Brunei” OR “Myanmar” OR “Cambodia” OR “Indonesia” OR “Laos” OR “Malaysia” OR “Philippines” OR “Singapore” OR “Thailand” OR “Timor-Leste” OR “Vietnam”). The search incorporated standardized terminology, including Medical Subject Headings (MeSH), to ensure thorough literature retrieval.

Two reviewers (M.R.G. and R.B.D.) independently conducted the study selection. The process began with screening titles and abstracts to capture research that aligns with the predefined inclusion criteria using the Covidence reference manager.[8] Full-text articles of the selected records were then assessed based on the eligibility criteria. After reaching consensus on the final list of included studies, another two reviewers independently extracted the necessary data (L.R.D. and R.B.D.). Any discrepancies during the screening or extraction process were addressed through consensus-based discussion with a third reviewer.

Quality Assessment and Outcome

The quality appraisal of non-randomized studies was conducted using the Newcastle-Ottawa Scale. Two reviewers independently assessed the quality of the studies (R.B.D. and L.R.D.), with any disagreement being resolved through discussion or consensus through a third reviewer (M.R.G.).[9] Key outcomes assessed included the percentage of participants who reached a functional neurological independence, as defined by a modified rankin scale score of between 0 and 2 at 90 days assesment, along with the success rate of blood vessel recanalization assessed by Thrombolysis In Cerebral Infarction (TICI) score of between 2b or 3, both indicators of treatment efficacy. For safety evaluation, outcomes such as the rate of symptomatic intracranial hemorrhage (sICH) and the overall 90-day mortality rate were analyzed. Additional data collected included demographic information such as age and gender, as well as the initial severity of stroke, measured using the National Institutes of Health Stroke Scale (NIHSS).

Statistical Analysis

Weighted pooled estimates for each outcome were computed using a random-effects model based on the DerSimonian and Laird method, which accounts for variability both within and across studies; however, in the case of analysis consisting of only two studies, a fixed effect model was employed. To evaluate the degree of inconsistency across studies, the I² statistic was used, representing the percentage of total variation due to heterogeneity rather than random chance. An I² value exceeding 50% was interpreted as indicating significant heterogeneity. Subgroup analysis was conducted based on country region, study design (retrospective and prospective), and quality of the studies. Forest plots illustrated the prevalence and overall pooled estimates, accompanied by 95% confidence intervals (CIs). Funnel plots were not used to grade publication bias because the analysis involved single-arm data. All statistical computations were performed using Jamovi version 2.3.28, with a predefined significance criterion of a p-value below 0.05 to ensure the robustness of the finding.[10] [11]

Results

Relevant literature was retrieved using the PubMed and Scopus databases, yielding 37 and 14 records, respectively. Additionally, six more records were identified through citation tracking. After eliminating 9 duplicate entries, 48 unique records remained for initial screening. After reviewing titles and abstracts, 31 records were excluded due to a lack of relevance. The remaining 17 articles were assessed in full text, all of which were successfully retrieved. Of these, five articles were excluded: one for reporting unrelated outcomes, three for involving inappropriate study populations, and one for not meeting the required study design criteria. As a result, 12 studies fulfilled all eligibility requirements and were included in the final review ([Fig. 1]).

Fig. 1 Flowchart of the included studies.

Background and Quality of Selected Publications

This review included 12 observational studies. Although this review focuses on Southeast Asia, eligible studies were identified from five countries only, comprising both retrospective and prospective designs. The majority were retrospective. Studies originated from Indonesia, Thailand, Vietnam, Philippines, and Singapore. We found only one multicenter study, the PROSPR-SEA study. Most patients were treated within a 6- to 24-hour window from stroke onset, with anterior circulation strokes being most commonly reported. Several studies also included posterior circulation cases and used imaging criteria for extended time windows. Consistent reported outcomes included NIHSS scores, functional independence (mRS 0–2), recanalization rates, sICH, and mortality. However, a study from Singapore reported the sICH outcome only. Three of the studies were assessed to be of good quality, while the remaining nine were considered to be of poor quality ([Table 1] and [Supplementary Material Table S1], available in the online version).

Table 1 Summary of the included studies

Author, year	Country	Study design	Age	Sex, males	NIHSS	mRS (0–2)	Total	Recanalization	Total	sICH	Total	Mortality	Total	Window period	Affected circulation	Posterior stroke
Kurniawan et al,[12] 2023	Indonesia	Retrospective	Mean, 56.75 (SD ± 12.21)	71.9%	Median, 13 (IQR, 8–24)	9	32	20	32	NA	NA	12	32	8 hours SO could be extended to 24 hours in evidence of mismatch	Anterior	NA
Mesiano et al,[5] 2021 (EVT only)	Indonesia	Retrospective	Median, 55 (IQR, 38.00–79.00)	86.7%	Median, 13 (IQR,3–24)	NA	NA	8	15	NA	NA	NA	NA	6 hours SO	Anterior and Posterior	20%
Mesiano et al,[5] 2021 (EVT + IVT)	Indonesia	Retrospective	Median, 56.5 (IQR, 37.00–85.00)	42.9%	Median, 13 (IQR, 10–21)	NA	NA	7	14	NA	NA	NA	NA	6 hours SO	Anterior	NA
Boonchai,[13] 2021	Thailand	Retrospective	Median, 65 (IQR, 57–82)	55.9%	Median, 16 (IQR, 13–20)	13	34	17	34	1	34	7	34	Anterior circulation: 8 Hours SO posterior circulationg: 12 hours SO	Anterior and Posterior	17.6%
Churojana et al,[14] 2017	Thailand	Retrospective	Mean, 61.4 (SD ± 14.5)	48.8%	Mean, 19.4 (SD + 5.52)	NA	NA	NA	NA	5	41	NA	NA	Anterior circulation: 4.5-8 hours, Posterior circulation: 4.5-24 hours	Anterior and Posterior	17.1%
Luu et al,[15] 2020	Vietnam	Retrospective	Mean, 61.29 (SD ± 14.49)	52.1%	Mean, 17.1 (SD ± 5.3)	37	73	53	73	14	73	18	73	24 hours SO	Anterior and Posterior	16.4%
Pham et al,[4] 2025	Vietnam	Prospective	Median, 66 (IQR, 59–76)	68.9%	Median, 13 (IQR, 9.0–17.0)	56	122	102	122	8	122	13	122	6-24 hours SO	Anterior	NA
Phuoc et al,[16] 2020	Vietnam	Retrospective	Mean, 61.4 (SD ± 13.4)	29.7%	Mean, 17.3 (SD ± 6.9)	21	37	30	37	NA	NA	6	37	6 hours SO	Anterior and Posterior	13.5%
Anh et al,[17] 2022	Vietnam	Prospective	Mean, 65 (SD ± 13)	55%	Mean, 14.3	148	227	192	227	8	227	NA	NA	6 hours SO Later than 6 hours will need imaging	Anterior and Posterior	9.7%
Ngoc et al,[18] 2021	Vietnam	Retrospective	62.14 ± 13.3	NA	Median, 16.2 ± 7.85	93	269	162	269	27	269	48	269	NA	NA	NA
Constantino et al,[19] 2023	Philippine	Retrospective	Mean, 64 (IQR, 60–71)	54.8%	Median, 14 (IQR, 11–19)	NA	NA	24	31	5	31	NA	NA	24 hours SO	Anterior and Posterior	6.4%
Lee et al,[20] 2009	Singapore	Prospective	Median, 67 (IQR, 61.5–76)	87%	Median, 17.88	NA	NA	NA	NA	1	17	NA	NA	8 hours SO	Anterior and Posterior	60%
Nguyen et al,[21] 2023	Vietnam, Thailand, and Singapore	Prospective	Mean, 64.9 (SD ± 13.7)	50.3%	Mean, 15.2 (SD ± 5.9)	112	180	172	183	14	183	14	183	8 hours SO	Anterior and Posterior	5.4%

Abbreviations: EVT, endovascular thrombectomy; IQR, interquartile range; IVT, intravenous thrombolysis; mRS, modified Rankin scale; NA, not available; NIHSS, National Institutes of Health Stroke Scale; SD, standard deviation; sICH, symptomatic intracranial hemorrhage: SO, symptom onset.

Thrombectomy Outcome

The included studies reported a mean or median age ranging from 55 to 67 years. The proportion of male patients varied between 29.7 and 87%. Stroke severity on admission, measured by the NIHSS, had median or mean scores ranging from 13 to 19.4.

A favorable functional independence status (mRS 0–2) was observed among the clinical outcomes assessed in 489 out of 974 patients. Successful recanalization, indicated by TICI grades (2b/3), was achieved in 787 out of 1,037 patients. sICH was documented in 83 out of 997 patients. Mortality was reported in 118 out of 750 patients. Detailed data for each study are presented in [Table 1].

Meta-analysis of Thrombectomy

This meta-analysis synthesized data from 12 Southeast Asian studies to examine key clinical outcomes of mechanical thrombectomy. The aggregated proportion of patients who achieved favorable functional independence (mRS 0–2) was 48.3% (95% CI: 38.9–57.8%; I² = 88.06%) ([Fig. 2]). Recanalization success, defined as achieving TICI grade 2b/3, was observed in 72.3% (95% CI: 63.3–81.2%; I² = 91.86%) of cases ([Fig. 3]). The rate of sICH was 7.95% (95% CI: 4.9–11%; I² = 64.85%) ([Fig. 4]), while the pooled mortality rate reached 17.3% (95% CI: 11–23.6%; I² = 80.69%) ([Fig. 5]).

Fig. 2 Meta-analysis forest plot: rates of modified Rankin scale (mRS) 0 to 2 outcomes at 90 days. RE, random effect.

Fig. 3 Meta-analysis forest plot: thrombolysis in cerebral infarction (TICI) grade 2b or 3 recanalization rates. The article written by Mesiano et al⁵ was separated into two studies because it described two distinct thrombectomy populations (one receiving intravenous thrombolysis [IVT] and mechanical thrombectomy [MT] and another receiving MT alone). RE, random effect.

Fig. 4 Meta-analysis forest plot: complication rates of symptomatic intracranial hemorrhage. RE, random effect.

Fig. 5 Meta-analysis forest plot: 90-day mortality rates post-stroke. RE, random effect.

Subgroup analyses revealed that prospective studies reported better outcomes than retrospective ones: mRS 0 to 2 was achieved in 58.1% versus 41.3%, recanalization was higher (87.8% vs. 65.4%), and both sICH (5.48% vs. 11%) and mortality (8.65% vs. 20.9%) were lower. Among countries, Vietnam contributed the most studies and outcomes varied among the included countries. These findings highlight regional differences and emphasize the impact of study design and healthcare system variability on stroke outcomes in Southeast Asia. Good quality studies showed lower rates of symptomatic intracranial hemorrhage (3.4% vs. 9.36%) and higher mortality (27.3% vs. 14.5%), while functional outcomes (mRS 0–2) and recanalization rates were similar across quality groups ([Table 2]).

Table 2 Subgroup analysis of the included studies

Characteristics	No. of studies	mRS (0–2)	No. of studies	Recanalization	No. of studies	sICH	No. of studies	Mortality
ALL	8	48.3% (95%CI, 38.9 -57.8%; I2 = 88.06%; p ≤ 0.001)	10	72.3% (95%CI, 63.3–81.2%; I2 = 91.86%; p ≤ 0.001)	9	7.95% (95%CI, 4.9–11%; I2 = 64.85%; p = 0.004)	7	17.3% (95%CI, 11 -23.6%; I2 = 80.69%; p ≤ 0.001)
Countries
Vietnam	5	50.3% (95%CI, 39.3–61.3%; I2 = 88.13%; p ≤ 0.001)	5	76.3% (95%CI, 66.8–85.9%; I2 = 88.82%; p ≤ 0.001)	4	8.78% (95%CI, 3.2–14.4%; I2 = 86.5%; p ≤ 0.001)	4	16.6% (95%CI, 11–22.3%; I2 = 59.8%; p = 0.065)
Thailand	1	38% (95%CI, 22–55%;)	1	50% (95% CI, 33–67%;)	2	5.19% (95%CI, 3-10.1; I2 = 59.7%; p = 0.115) FE	1	21% (95%CI, 7–34%;)
Singapore	NA	NA	NA	NA	1	6% (95% CI, −5–17%;)	NA	NA
Indonesia	1	28% (95%CI, 13–44%)	2	57.5% (95%CI, 45.2–69.9%; I2 = 0%; p = 0.684)	NA	NA	1	38% (95%CI, 21–54%;)
Philippines	NA	NA	1	77% (95%CI, 63–92%;)	1	16% (95%CI, 3–29%;)	NA	NA
Study Design
Prospective	3	58.1% (95% CI, 46.7–69.6%; I2 = 86.46%; p = 0.002)	3	87.8% (95% CI, 81–94.5%; I2 = 83.38%; p ≤ 0.001)	4	5.48% (95% CI, 2.9–8.1%; I2 = 35.29%; p = 0.286)	2	8.65% (95% CI, 5.5–11.8%; I2 = 0%; p = 0.379) FE
Retrospective	5	41.3% (95%CI, 31.5 -51.1%; I2 = 69.73%; p = 0.012)	7	65.4% (95%CI, 57.2–73.5%; I2 = 64.71%; p = 0.009)	5	11% (95%CI, 5.3–16.7%; I2 = 67.57%; p = 0.028)	5	20.9% (95%CI, 15.8 -26%; I2 = 26.46%; p = 0.180)
Quality
Poor	5	49.5% (95%CI, 39.3 -59.6%; I2 = 84.98%; p ≤ 0.001)	7	74.1% (95%CI, 63.9–84.3%; I2 = 90.79%; p ≤ 0.001)	7	9.36% (95%CI, 6.9–11.8%; I2 = 17.61%; p = 0.192)	5	14.5% (95%CI, 8.7 -20.3%; I2 = 77.65%; p ≤ 0.001)
Good	3	44.9% (95%CI, 22.3–67.5%; I2 = 89.8%; p ≤ 0.001)	3	67% (95%CI, 46.3–87.8%; I2 = 87.61%; p ≤ 0.001)	2	3.4% (95%CI, 1.2–5.6%; I2 = 0%; p = 0.853) FE	2	27.3% (95%CI, 16.7–37.9%; I2 = 57.58%; p = 0.125) FE

Abbreviations: FE, fixed effect; mRS, modified Rankin scale; NA, not available; sICH, symptomatic intracranial hemorrhage.

Discussion

This review showed that mechanical thrombectomy in Southeast Asia resulted in 48.3% favorable functional independence outcomes and 72.3% successful recanalization. The rates of sICH and mortality were 7.95 and 17.3%, respectively. Prospective studies reported better outcomes than retrospective ones. Vietnam contributed the most studies, with outcomes varying among the included countries, with no major differences in outcome between good and poor quality studies.

This review identified studies from five Southeast Asian nations: Vietnam, Singapore, Indonesia, Philippines, and Thailand. These studies demonstrate that MT is being implemented in clinical practice within these regions. Evidence derived from the MT-GLASS study conducted by Asif et al supports this observation.[22] Most of the included data from these countries were sourced from public or academic medical centers, a factor that could potentially influence the reported clinical outcomes. Previous studies have indicated that patients treated in private healthcare settings often experience better outcomes than those treated in public institutions.[23]

In comparison with the HERMES collaboration, which aggregated results from five randomized clinical trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), our findings demonstrated similar rates of favorable functional independence outcomes and vessel recanalization. Within the HERMES dataset, 46% of participants attained functional independence mRS (0–2) and 71% achieved successful recanalization. In contrast, our pooled analysis yielded a 48.3% rate for mRS (0–2) and 72.3% for recanalization. However, the occurrence of sICH was higher in our review (7.95% vs. 4.4%), and mortality was slightly higher (17.3% vs. 15.3%). These findings suggest that, despite differences in study design, healthcare infrastructure, and resource availability, mechanical thrombectomy outcomes in Southeast Asia are largely comparable to those reported in Western high-income countries.[2] However, the higher sICH rates and mortality observed may reflect delays in presentation, limited neuroimaging access, procedural challenges, or variations in post-procedural care.[24]

Subgroup analysis highlighted variability in outcomes across the included countries. Vietnam contributed the majority of studies and reported relatively favorable functional independence and recanalization rates. Meanwhile, studies from Indonesia, Singapore, Thailand, and the Philippines showed varied results. These differences likely reflect disparities in healthcare infrastructure, access to MT-capable centers, and stroke care systems. Factors such as treatment delays, limited resources, and financial barriers may influence the effectiveness of MT across the region. These findings underscore the importance of strengthening stroke systems.[24] [25] [26]

Studies employing a prospective design showed better outcomes than retrospective studies. Functional independence was achieved in 58.1% of patients in prospective studies compared to 41.3% in retrospective ones, and recanalization rates were higher (87.8% vs. 65.4%). Rates of sICH and mortality were also lower in prospective studies. The superior results yielded by prospective studies in meta-analyses can be attributed to several methodological advantages inherent in their design. Prospective studies allow for the pre-specification of study selection criteria, hypotheses, and analysis methods before any study results are known, which significantly reduces biases such as publication bias and selective outcome reporting.[27] [28] Additionally, prospective studies often apply narrower, more standardized selection criteria, increasing the likelihood of favorable outcomes. They may also include more recent cases, benefiting from improved thrombectomy devices, greater operator experience, better imaging, and procedural protocols. Combined with reduced risk of bias through pre-specified analysis plans, these factors contribute to the superior results observed.

The findings of this review highlight that MT can achieve functional and safety outcomes in Southeast Asian countries comparable to those reported in Western high-income nations, despite existing resource limitations, However, it should be acknowledged that outcome variability exists across Southeast Asian countries, likely reflecting differences in healthcare infrastructure, stroke system maturity, access to neuro-interventional services, and available resources. Nonetheless, this study encourages greater utilization, and emphasizes the potential benefits of expanding MT programs across Southeast Asia, even within resource-constrained environments. Enhancing public awareness, promoting earlier hospital presentation, and improving access to neuro-interventional care could substantially improve stroke outcomes in the region. Policymakers and healthcare stakeholders should prioritize the strengthening of stroke care systems, including the development of more MT-capable centers and the subsidization of treatment costs to reduce financial barriers.

Future research should focus on generating prospective, multicenter registries across a broader range of Southeast Asian countries to capture more representative and robust real-world data. Research exploring cost-effectiveness and equity in access to MT, especially in rural and underserved populations, is warranted. Moreover, qualitative studies investigating patient, provider, and system-level barriers to timely thrombectomy could offer actionable insights for programmatic improvement.

Limitations

Several limitations should be acknowledged in this review. First, the majority of the included studies were retrospective in nature, which inherently carries risks of selection bias and missing data. Second, heterogeneity in study designs, stroke severity, imaging protocols, and time windows for thrombectomy across studies may affect the generalizability of pooled estimates, for example, the earlier the MT is performed, the better the outcomes, but late-window MT remains effective for carefully selected patients using advanced imaging. Third, the included studies predominantly originated from a limited number of countries, largely due to the scarcity of published data. This may have led to the underrepresentation of nations where mechanical thrombectomy is still emerging but remains underreported in the literature. As such, the interpretation of findings should be approached with caution, particularly when generalizing across the broader Southeast Asian region. Fourth, the overall study quality was modest, with 9 of the 12 studies rated as poor based on the Newcastle-Ottawa Scale. However, from the subgroup analysis, we found that there are no major differences between good and poor quality studies. Fifth, there is a potential for overlapping patient data from countries with multiple studies from the same centers. Lastly, publication bias could not be formally assessed due to the single-arm nature of the pooled analysis.

Conclusion

This review shows that mechanical thrombectomy outcomes in Southeast Asia are comparable to those in Western high-income countries, despite resource limitations. Regional disparities were noted, reflecting differences in healthcare infrastructure. These findings advocate the feasibility of expanding MT programs in Southeast Asia.

• References

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