Visual Tools for Informed Decision-Making in Large-Core Thrombectomy for Acute Ischemic Stroke

Recent randomized clinical trials have demonstrated that endovascular thrombectomy (EVT) improves outcomes in patients with large ischemic cores. Despite these findings, hyperacute decision-making in large-core acute ischemic stroke remains challenging, as patients continue to face high rates of disability and mortality. Clear communication of risks and benefits is essential, and visual aids may improve comprehension in emergency settings.

Ninety-day modified Rankin Scale score distributions were pooled from 6 large-core thrombectomy trials: RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial), SELECT-2 (Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke), ANGEL-ASPECT (Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core), TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), and LASTE (Large Stroke Therapy Evaluation). Outcomes included functional independence (modified Rankin Scale score, 0-2), acceptable outcome (modified Rankin Scale score, 0-3), symptomatic intracranial hemorrhage, and decompressive hemicraniectomy. Benefit per hundred and harm per hundred were calculated by comparing EVT with medical management. Net benefit was defined as benefit per hundred minus harm per hundred. Visual decision aids, including a Single Personograph Choice Consequence Matrix, were developed to illustrate the pooled results.

Across 1872 patients, EVT increased rates of functional independence (19.5% versus 7.5%) and acceptable outcomes (36.5% versus 20.0%) compared with medical management. EVT also reduced severe disability (12.2% versus 20.6%) and mortality (31.0% versus 37.2%). Rates of symptomatic intracranial hemorrhage were 5.5% in the EVT arm and 3.2% in the medical management arm, while hemicraniectomy occurred in 12.1% and 10.4%, respectively, corresponding to an excess harm of 3.9%. The calculated benefit per hundred ranged from 16.5% (modified Rankin Scale score, 0-2) to 55.6% (ordinal shift), with an average of 36.1%. The visual aid illustrated that when scaled to a cohort of 100 patients receiving EVT, 40 would be expected to benefit, 4 to experience harm, 31 to die, and 29 to show no difference compared with medical management.

EVT for large-core acute ischemic stroke provides substantial benefit despite increased risks of hemorrhage and surgical rescue. Visual decision aids based on pooled trial data offer an objective method for presenting outcomes, supporting informed and timely decision-making in acute stroke care.