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Admission Phenotype Clarifies the Apparent Prognostic Contrast Between TOAST Etiologic Subtypes in Large-Core

Chengsong Yue1,2, Shihai Yang2, Xiongxiong Hou3

  • 1Department of Neurology, No. 924 Hospital of Joint Logistic Support Force of Chinese PLA, GuangXi, China.

CNS Neuroscience & Therapeutics
|July 14, 2026
PubMed

Insights

Prognostic differences between large-artery atherosclerosis (LAA) and cardioembolism (CE) stroke etiologies in large-vessel occlusion (LVO) are explained by clinical-imaging profiles. These factors, not etiology alone, should guide hyperacute endovascular thrombectomy (EVT) selection.

Area of Science:

  • Neurology
  • Interventional Neurology
  • Stroke Medicine

Background:

  • Large-vessel occlusion (LVO) stroke prognosis varies by etiology, specifically large-artery atherosclerosis (LAA) versus cardioembolism (CE).
  • Admission clinical-imaging profiles complicate the interpretation of prognostic differences between LAA and CE.
  • Understanding these differences is crucial for optimizing treatment strategies.

Purpose of the Study:

  • To determine if prognostic differences between LAA and CE persist after adjusting for clinical and imaging factors in anterior circulation LVO.
  • To investigate whether the association between endovascular thrombectomy (EVT) and patient outcomes differs based on stroke etiology (LAA vs. CE).

Main Methods:

  • Analysis of 631 patients with ASPECTS ≤ 5 from the MAGIC registry.
  • Comparison of outcomes between 404 patients treated with EVT plus medical therapy and 227 treated with medical therapy alone.
  • Use of mixed-effects models to assess etiology-outcome associations and treatment-by-etiology interactions; Shapley decomposition for EVT-treated patients.

Main Results:

  • Crude odds of favorable outcomes (mRS 0-3) were higher with LAA in EVT-treated patients but attenuated after adjustment (aOR 0.92).
  • No adjusted prognostic contrast between LAA and CE was observed with medical therapy alone (aOR 1.12).
  • Pretreatment factors, particularly imaging and collateral status, attenuated the LAA-CE prognostic contrast by 96.2% in EVT patients; adjusted odds for mRS 0-2 favored CE (aOR 0.46).

Conclusions:

  • Admission clinical-imaging phenotypes explain the apparent prognostic differences between LAA and CE in LVO.
  • These findings support using established clinical-imaging criteria for hyperacute EVT selection, rather than relying solely on LAA versus CE etiology.
  • Reconciliation of discordant findings across EVT cohorts is facilitated by considering these phenotypes.
Abstract

Keywords:
collateral circulationendovascular thrombectomylarge‐core ischemic strokestroke etiology

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