Endovascular treatment and outcome in patients with CTP-defined extra-large infarct core stroke

BACKGROUND AND PURPOSE: Evidence for endovascular thrombectomy (EVT) in patients with very large perfusion-defined infarct core stroke remains limited. METHODS: We performed a retrospective multicenter cohort study using prospectively maintained stroke registries from nine comprehensive stroke centers in China between 1 June, 2019 and 1 June, 2025. Adults with anterior circulation large-vessel occlusion involving the internal carotid artery or middle cerebral artery M1/M2 segment, presentation within 24 hours, and baseline CT perfusion (CTP)-defined ischemic core volume ≥100 mL were included. Ischemic core was defined as relative cerebral blood flow of <30%. The primary outcome was a favorable functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score of 0-3. Multivariable regression and Inverse Probability of Treatment Weighting (IPTW) were used. RESULTS: Among 327 patients (median age 74 years; 146 women), 203 underwent EVT and 124 received best medical management. Successful reperfusion was achieved in 181/203 EVT-treated patients (89.1%). EVT was associated with higher odds of a favorable functional outcome (19.7% vs 5.6%; adjusted OR (aOR) 4.3, 95% CI 1.6 to 11.6, P=0.004; IPTW aOR 5.1, 95% CI 2.1 to 12.3, P<0.001 lower 90-day mortality (49.3% vs 70.2%; aOR 0.5, 95% CI 0.3 to 0.8, P=0.009), and a higher risk of symptomatic intracranial hemorrhage (25.6% vs 8.1%; aOR 4.4, 95% CI 2.0 to 9.8, P<0.001). CONCLUSION: In this multicenter cohort of patients with anterior circulation large-vessel occlusion and CTP-defined ischemic core volume of ≥100 mL, EVT was associated with a better functional outcome and lower mortality, but a favorable outcome remained uncommon and mortality remained high, with an increased risk of symptomatic intracranial hemorrhage. Prospective validation is needed.