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The Large Core Paradox.

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Endovascular treatment (EVT) shows benefits for large-core stroke, challenging traditional models. Further research is needed for accurate assessment of irreversible brain injury in these patients.

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Area of Science:

  • Neurology
  • Interventional Radiology

Background:

  • Recent randomized controlled trials (RCTs) demonstrate endovascular treatment (EVT) benefits over medical management for anterior circulation large vessel occlusion (LVO) with large core infarcts.
  • A recent trial also reported EVT benefit in the very large-core category (Alberta Stroke Program Early CT Score 0-2).
  • These findings contradict the established view that large infarct cores preclude good outcomes after reperfusion, prompting questions about the core/penumbra model's validity.

Purpose of the Study:

  • To discuss recent trial results regarding EVT for large-core stroke.
  • To propose alternative explanations for the observed "large-core paradox."
  • To highlight the need for improved methods in assessing irreversible neuronal injury for EVT eligibility.

Main Methods:

  • Review and discussion of data from 6 RCTs on EVT vs. medical management for large-core LVO.
  • Analysis of findings from a trial reporting EVT benefit in the very large-core category.
  • Consideration of imaging accuracy, penumbral salvage, and vasogenic edema in large-core stroke.

Main Results:

  • Despite EVT improving outcomes, approximately 80% of treated patients still have poor functional outcomes.
  • Imaging assessment of infarct core size, particularly with CT, may be inaccurate in early time windows.
  • Substudy analyses suggest EVT benefits may stem from salvaging penumbra, present in a significant portion of patients.
  • Reduced perfusion in large cores can lead to vasogenic edema, potentially overestimating infarct size on imaging.

Conclusions:

  • EVT offers benefits in large-core stroke, but overall outcomes remain suboptimal.
  • Accurate assessment of infarct core and presence of salvageable penumbra is crucial for EVT decision-making.
  • Early reperfusion aims to salvage penumbra and prevent edema in large-core stroke patients.
  • More reliable methods are needed to identify irreversible neuronal injury within imaging-defined infarct cores.