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Endovascular thrombectomy for large infarcts in acute ischemic stroke: does size still matter?
  1. Permesh Singh Dhillon1,2,3,
  2. Laetitia De Villiers1,
  3. Vinicius Carraro do Nascimento1,
  4. Luis Domitrovic1,
  5. Bruce C V Campbell4,5,
  6. Hal Rice1
  1. 1 Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia
  2. 2 Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
  3. 3 Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
  4. 4 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  5. 5 Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
  1. Correspondence to Dr Permesh Singh Dhillon; permesh.dhillon{at}nottingham.ac.uk

https://doi.org/10.1136/jnis-2023-021188

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    Endovascular thrombectomy (EVT) for large vessel occlusion in acute ischemic stroke is the standard of care when initiated within 24 hours of stroke onset or last known well.1 2 Current guidelines strongly recommend EVT in a broad range of patients with large vessel occlusion, within 6 hours after stroke onset, and more restricted groups with a small ischemic core volume and clinical or perfusion mismatch according to the DAWN (Clinical Mismatch in the Triage of Wake up and Late Presenting Strokes Undergoing Neurointervention with Trevo Thrombectomy Procedure) or DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischaemic Stroke 3) criteria, in the late window (6 to 24 hours).1 2 Although a small proportion of patients with a ‘large ischemic core’ (Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less) were included and appeared to benefit from EVT treatment in the landmark randomized controlled trials in 2015, the overall modest pooled sample size in the HERMES collaboration prevented definitive conclusions being made about the net treatment benefit and safety in this patient cohort.3 Recently, the final ‘large ischemic core’ trials, TESLA and LASTE, were presented (although not yet published) in addition to TENSION, which was recently published, after the publication of the RESCUE Japan LIMIT, SELECT 2, and ANGEL-ASPECT trials.4–9 These trials which broadly included adult patients with an ASPECTS of 5 or less on computerized tomography (CT) or magnetic resonance (MR) imaging, or with an ischemic core volume of larger than 50 mL, demonstrated significantly improved functional outcomes and comparable safety profiles among patients who underwent EVT, up to 24 hours from stroke onset, compared with those without EVT treatment, despite the less favorable imaging profiles.

    An initial concern for many practitioners in treating patients with a large ischemic core included the higher risk of developing symptomatic intracranial …

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    Footnotes

    • X @PermeshSD, @carrarovini

    • Contributors PSD drafted the initial manuscript. All authors revised and approved of the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests BCVC was a site principal investigator for the SELECT 2 trial (Trial of endovascular thrombectomy for large ischemic strokes). No other disclosures or competing interests declared by the remaining authors.

    • Provenance and peer review Not commissioned; externally peer reviewed.