Current perspectives on endovascular therapy for large core ischemic stroke

Historically, patients with ischemic stroke and an extensive region of irreversibly injured ischemic core were excluded from endovascular thrombectomy trials due to concerns about limited benefit and high procedural risk. This has fundamentally changed with the publication of five strongly positive randomized controlled trials in this group of patients since 2022 and a sixth trial that showed consistent trends and was positive in per protocol analysis and long-term follow-up. This narrative review summarizes the key findings of these trials, including imaging selection criteria, functional and safety outcomes, and long-term benefits. Across trials, thrombectomy consistently improved functional outcomes at 3-months and 12-months. Absolute functional independence (modified Rankin Scale score 0-2) rates were lower than the trials that enrolled patients with smaller ischemic core volumes, but still significantly favored thrombectomy. Safety outcomes demonstrated a reduction in mortality with EVT and no significant increase in rates of symptomatic intracerebral hemorrhage. While guidelines are being updated to include large core thrombectomy, real-world decision-making remains complex, requiring careful consideration of patient-specific factors, including functional status, infarct location, and patient preferences. Future research should focus on exploring adjunctive therapies and accelerated systems of care to further improve outcomes in this patient population.