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Publications

Journal Article Ahead of print

PubMed: 42403349 DOI: 10.1161/STROKEAHA.126.055374

Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS.

Stroke

Authors: Hokyu Kim, Wi-Sun Ryu, Manabu Inoue, Leonard Sunwoo, Kyusik Kang, Jae Guk Kim, Soo Joo Lee, Jae-Kwan Cha, Tai Hwan Park, Jeong-Yoon Lee, Kyungbok Lee, Doo Hyuk Kwon, Jun Lee, Hong-Kyun Park, Keun-Sik Hong, Minwoo Lee, Mi Sun Oh, Kyung-Ho Yu, Dong-Seok Gwak, Dong-Eog Kim, Hyunsoo Kim, Joon-Tae Kim, Joong-Goo Kim, Jay Chol Choi, Wook-Joo Kim, Jee Hyun Kwon, Kyu Sun Yum, Dong-Ick Shin, Jeong-Ho Hong, Sung-Il Sohn, Sang-Hwa Lee, Chulho Kim, Hae-Bong Jeong, Kwang-Yeol Park, Keon-Joo Lee, Chi Kyung Kim, Jihoon Kang, Jun Yup Kim, Hee-Joon Bae, Beom-Joon Kim

Affiliations

  • Department of Neurology, Korea University Guro Hospital, Seoul (Hokyu Kim, K.-J.L. C.K.K.).
  • Artificial Intelligence Research Center, JLK Inc, Seoul, Korea (W.-S.R.).
  • Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.).
  • Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (L.S.).
  • Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea (K.K.).
  • Department of Neurology, Eulji University School of Medicine, Daejeon Eulji Medical Center, Korea (J.G.K. S.J.L.).
  • Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C.).
  • Department of Neurology, Seoul Medical Center, Korea (T.H.P.).
  • Department of Neurology, Soonchunhyang University Seoul Hospital, Korea (J.-Y.L. K.L.).
  • Department of Neurology, Yeungnam University Medical Center, Daegu, Korea (D.H.K. J.L.).
  • Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (H.-K.P. K.-S.H.).
  • Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (M.L. M.S.O. K.-H.Y.).
  • Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-S.G. D.-E.K.).
  • Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea (Hyunsoo Kim, J.-T.K.).
  • Department of Neurology, Jeju National University Hospital, Korea (J.-G.K. J.C.C.).
  • Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Korea (W.-J.K. J.H.K.).
  • Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (K.S.Y. D.-I.S.).
  • Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea (J.-H.H. S.-I.S.).
  • Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Korea (S.-H.L. C.K.).
  • Department of Neurology, Chung-Ang University Hospital, Seoul, Korea (H.B.J. K.-Y.P.).
  • Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (J.K. J.Y.K. H.-J.B. B.-J.K.).

Abstract

BACKGROUND

Recent trials established the efficacy of thrombectomy for large-core stroke by utilizing the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) as a pragmatic tool. However, whether this topographical scoring captures the therapeutic ceiling, or the upper threshold of infarct volume where the benefit of reperfusion diminishes, remains unclear.

METHODS

Leveraging a nationwide multicenter registry in Korea (2022-2024), we compared the prognostic value of quantitative volumetry and ASPECTS in thrombectomy-treated patients. We analyzed discordance between ASPECTS and volumetry derived from diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography. The primary outcome was poor functional outcome (90-day modified Rankin Scale score 5-6). To estimate treatment effects across specific volume spectra, we conducted target trial emulations that stratified causal estimates by volumetric thresholds, with the ordinal 90-day modified Rankin Scale score shift as the primary outcome.

RESULTS

Among 552 patients, the mean age was 70.4±12.6 years, and 319 (57.8%) were men. Patients classified as large core by ASPECTS but not by diffusion-weighted imaging volumetry (ASPECTS-only large core) had poor outcome proportions comparable to the both small-core group (11.8% versus 11.7%), with no excess risk after adjustment. Conversely, volumetric confirmation of large core across diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography consistently predicted poor prognosis regardless of ASPECTS (adjusted odds ratio, 6.92 [95% CI, 2.58-19.34] for the diffusion-weighted imaging-only large-core group). In the target trial emulations, the overall benefit of thrombectomy was attenuated (common odds ratio, 0.56 [95% CI, 0.31-1.03]). Stratified analyses delineated a therapeutic ceiling, with benefit in the 50 to 110 mL range (common odds ratio, 0.38 [95% CI, 0.15-0.97]) disappearing in extensive infarctions >110 mL.

CONCLUSIONS

Quantitative volumetry provided better prognostic discrimination and identified ≥110 mL as a therapeutic ceiling where the benefit of thrombectomy becomes negligible. These findings advocate integrating volumetric thresholds into patient selection to minimize futile reperfusion and prioritize safety, serving as a critical refinement to current topographical scoring.

MeSH

Ischemic Stroke, Stroke, Tomography, Magnetic Resonance Imaging, Odds Ratio, Reperfusion, Cerebrovascular Disorders, Therapeutics, Thrombectomy