What question did this study set out to answer?

To determine if the benefit of thrombectomy for large strokes varies with perfusion-diffusion mismatch.

February 2, 2026Open Access

Does the Benefit of Thrombectomy in Large Strokes Depend on Perfusion–Diffusion Mismatch? A Large Stroke Therapy Evaluation Trial Post Hoc Analysis

ASAdrien ter Schiphorst CACaroline ArquizanInserm GTGuillaume TurcInserm

Key Points

To determine if the benefit of thrombectomy for large strokes varies with perfusion-diffusion mismatch.
Conducted a post hoc analysis of the LASTE randomized controlled trial.
Compared mechanical thrombectomy with best medical treatment against best medical treatment alone.
Included patients with large infarcts and available MR perfusion imaging.
Defined perfusion-diffusion mismatch using a specific ratio of cerebral volume to ischemic core volume.
Included 102 patients, with 54% showing perfusion-diffusion mismatch.
No significant differences in treatment effects based on mismatch presence for the primary outcome.
GenOR for better functional outcomes was similar across both groups with and without mismatch.

Abstract

Background and Purpose Whether perfusion-diffusion mismatch modifies treatment effect of mechanical thrombectomy (MT) for large strokes is poorly known. To address this question, we conducted a post hoc secondary analysis of the Large Stroke Therapy Evaluation (LASTE) randomized controlled trial (RCT).Methods The LASTE RCT compared MT plus best medical treatment (BMT) to BMT alone in patients with large infarct (Alberta Stroke Program Early CT Score 0–5) in the 0–7-hour timewindow. This secondary analysis was restricted to patients with available baseline MR perfusionweighted imaging. We investigated the potential heterogeneity of MT treatment according to the presence of perfusion-diffusion mismatch, defined as a mismatch ratio ≥1.2, calculated as the time-to-maximum >6 seconds cerebral volume divided by ischemic core volume. The primary outcome was better functional outcome (favorable shift in the distribution of modified Rankin Scale mRS at 90 days, analyzed using generalized odds ratio GenOR).Results A total of 102/324 patients were included, among whom 55 (54%) had a perfusiondiffusion mismatch. No significant treatment effect heterogeneity by diffusion-perfusion mismatch was observed for the primary outcome (GenOR for better functional outcome: 1.70 95% confidence interval, CI, 0.95 to 3.05 and 1.04 95% CI, 0.57 to 1.87 in patients with and without mismatch, respectively; ratio of GenORs: 1.63 95% CI, 0.71 to 3.74; P for heterogeneity=0.24) or for the secondary efficacy and safety outcomes.Conclusions Our study found no evidence of heterogeneity of treatment effect with respect to benefit or safety in patients with unrestricted infarct size at baseline treated with MT by presence of perfusion-diffusion mismatch. An individual participant-data meta-analysis of RCT is needed for definitive conclusions.

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