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Large Core Trial

Gianluca De Rubeis1, Sebastiano Fabiano2, Luca Bertaccini2

  • 1From the Department of Diagnostic (G.D.R., S.F., L.B., E.P.), UOC of Diagnostic and Interventional Neuroradiology, San Camillo-Forlanini Hospital, Rome, Italy derubeis.gianluca@gmail.com.

AJNR. American Journal of Neuroradiology
|March 13, 2025
PubMed

Insights

Large-core stroke trials show mechanical thrombectomy benefits, but ASPECT score limitations may affect results. Perfusion imaging is superior to ASPECT score for assessing ischemic core and salvageable tissue in stroke patients.

Area of Science:

  • Neurology
  • Interventional Neurology
  • Stroke Medicine

Background:

  • Recent large-core Randomized Controlled Trials (RCTs) evaluated mechanical thrombectomy for acute ischemic stroke.
  • Six RCTs demonstrated thrombectomy's superiority over medical treatment in patients with low ASPECTS scores.
  • The use of ASPECTS ( a 10-point scale) to define the ischemic core has limitations, particularly for changes beyond the middle cerebral artery (MCA) territory.

Purpose of the Study:

  • To critically analyze recent publications on large-core RCTs.
  • To evaluate the implications of using ASPECTS for defining the ischemic core on the external validity of these trials.
  • To compare the reliability of ASPECTS with perfusion imaging in assessing infarct core and salvageable brain tissue.

Main Methods:

  • Evaluated ASPECTS reliability by examining occlusion location, collateral blood flow, and perfusion imaging.
  • Compared data from the HERMES collaboration with six large-core RCTs.
  • Investigated the effect of occlusion site on infarct size and salvageable brain tissue.

Main Results:

  • RCTs showed a trend toward more proximal occlusions in large-core trials compared to the HERMES collaboration.
  • ASPECTS inadequately depicted ischemic changes outside proximal MCA occlusions, potentially leading to misinterpretations.
  • Perfusion imaging identified core volume and salvageable areas more accurately than ASPECTS alone.

Conclusions:

  • Perfusion imaging is superior to ASPECTS for assessing infarct core and salvageable tissue in large-core stroke RCTs.
  • Redefining infarct core assessment in large-core RCTs, prioritizing perfusion imaging over ASPECTS, is advocated.
  • Further research is needed to refine imaging criteria for thrombectomy eligibility, considering occlusion site significance.

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