Large Core Thrombectomy: Feasibility of Simplified Protocol in Resource-Limited Settings

Introduction Several trials have demonstrated the benefits of endovascular thrombectomy (EVT) for large-core strokes (ASPECTS < 6). However, its effectiveness in lower-middle-income countries with resource-limited settings remains uncertain. This study evaluated the feasibility of EVT for large-core strokes using a simplified imaging protocol with non-contrast CT (NCCT) and CT angiography (CTA) in a resource-constrained environment. Methods We conducted a prospective, single-center, observational study from May 2023 to May 2024 at Da Nang Hospital, Vietnam. Patients with anterior circulation large-vessel occlusion strokes, ASPECTS < 6 on NCCT, admission NIHSS ≥ 6, and EVT within 24 hours were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Functional independence was defined as mRS 0–2 and ambulatory independence as mRS 0–3. Safety outcomes included symptomatic intracranial hemorrhage (sICH). Outcomes were compared based on reperfusion success (mTICI ≥2b vs. 0–2a), ASPECTS (0–2 vs. 3–5), and time window (≤6 vs. >6 hours). Results Among 157 EVT-treated patients, 52 (33.1%) had ASPECTS < 6. The median age was 62.5 years, and 57.7% were male. Median onset-to-hospital time was 4.1 hours (IQR 1.8-7.9), admission NIHSS 15 (IQR 13-19.5), and initial ASPECTS 4 (IQR 3-4). Successful reperfusion (mTICI ≥2b) was achieved in 78.9%. At 90 days, the median mRS was 3.5 (IQR 3-5.5). Functional independence was observed in 23.1% and ambulatory independence in 50%. sICH occurred in 9.6%, and mortality was 25%. Successful reperfusion was the only independent predictor of ambulatory independence (OR 14.7, 95% CI 1.6–134). Patients with ASPECTS 3–5 had significantly higher ambulatory independence than those with ASPECTS 0–2 (58.5% vs. 18.2%, p=0.017). No significant differences were found between early and late-window groups. Conclusion EVT is feasible for large-core stroke patients in lower-income countries using a simplified NCCT-CTA protocol. Successful reperfusion is a key determinant of improved outcomes.