Background Randomized controlled trials show large infarct core patients do better when treated with endovascular thrombectomy (EVT) than medical management, with rates of functional independence at day-90 ranging from 14-30%. We aimed to determine the real-world benefit of EVT in large core patients.
Methods Consecutive patients with anterior large vessel occlusion treated with EVT between 2011 and 2024 were included. Patients were identified from a mandatory national stroke therapy registry. The setting is a tertiary EVT centre with a catchment of 2.8 million. Data recorded included demographics, stroke characteristics, complications and outcome. Large infarct core was defined as Alberta Stroke Program Early CT score (ASPECTS) of 2-5. The primary outcome was independence at day-90, defined as modified Rankin Scale (mRS) 0-2.
Results Of 1096 patients, 106 (9.7%) had ASPECTS 2-5, and 990 (90.3%) ASPECTS 6-10. At day-90, 35 (33.7%) large infarct core patients were independent, compared with 548 (56.2%) of the others (p<0.0001). ICU admission (14.2% vs 7.8%; p=0.43), hemicraniectomy (7.5% vs 1.0%; p<0.0001), length of stay (33 vs 19 days; p=0.001), and day-90 mortality (20.7% vs 13.7%; p=0.075) were higher for large core patients. Māori and Pasifika made up a higher proportion of the large core group (46.2% ASPECTS 2-5 vs 27.4% 6-10; p<0.0001).
Conclusion In this real-world study, EVT patients with large infarct cores did worse than others but one in three had independent outcomes. This compares favourably with the results from recent studies. The over-representation of Māori and Pasifika in the large core group requires further exploration.