Prevailing dogma in the treatment of acute ischemic stroke has long dictated that endovascular reperfusion of large infarcted areas distal to an occluded large intracranial artery is detrimental to patient outcomes. These concerns were rooted in the presumed deleterious effects of reperfusion, most notably symptomatic intracranial hemorrhage, and in the constrained opportunity to improve outcome due to the substantial infarction already present. Indeed, the initial waves of positive randomized endovascular stroke trials addressing thrombectomy in the early time window (0-6 hours) and with imaging selection in the late time window (6-24 hours) generally excluded from enrollment patients with a large baseline infarct (core). However, among the relatively small number of patients with large core infarcts inadvertently enrolled in these trials, analyses suggested an acceptable safety profile and potential benefit of thrombectomy. These rather unexpected findings led to the launch of several randomized trials prospectively assessing the efficacy and safety of thrombectomy in patients with acute ischemic stroke presenting with a large core and proximal large vessel occlusion in the anterior circulation. Across these trials, characterization of the infarcted brain has occurred with different imaging modalities using different definitions for what constitutes a large core, but common to all trials has been a requirement that infarction already be present on computed tomography (CT) or magnetic resonance imaging (MRI) in at least 5 of the 10 regions of the Alberta Stroke Program Early CT Score (ASPECTS) scale.
CT-Guided Thrombectomy for Large Core Stroke Up to 24 Hours
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Ottobre 2024
