Effectiveness of endovascular thrombectomy in large-core ischemic stroke: a real-world cohort study

Background The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke with large infarct cores in real-world practice remains uncertain, especially for patients beyond randomized trial criteria. Materials and methods We retrospectively analyzed adult patients (January 2020–September 2024) with anterior-circulation large-vessel occlusion, an NIHSS score of 6–30, and an ASPECTS of 0–5 or infarct core volume ≥70 mL, treated within 24 h. Inverse probability of treatment weighting (IPTW) was used to compare outcomes between EVT and standard medical treatment (SMT). The primary endpoint was functional independence (mRS 0–2) at 90 days. Results Among 300 eligible patients, EVT was associated with a higher likelihood of 90-day functional independence compared with SMT (18.0% vs. 5.0%; adjusted risk ratio, 2.82; 95% CI, 1.09–7.32; p = 0.033) and better mRS 0–3 outcomes after IPTW. While any intracranial hemorrhage was more frequent following EVT, the rates of symptomatic intracranial hemorrhage, 90-day mortality, and space-occupying brain edema did not differ significantly between groups. The estimated treatment effect generally favored EVT across the predefined subgroups, and no statistically significant evidence of treatment-effect heterogeneity was detected (all P for interaction > 0.05). However, several subgroup-specific estimates were imprecise, with confidence intervals crossing the null value. Notably, the treatment effect could not be estimated among patients with a baseline mRS ≥ 2 because no patient in this subgroup achieved functional independence. Conclusion In real-world practice, EVT within 24 h is associated with a higher likelihood of functional independence for selected patients with large-core stroke. EVT was associated with a higher incidence of any intracranial hemorrhage, although no statistically significant differences were observed in symptomatic intracranial hemorrhage, 90-day mortality, or space-occupying brain edema. Individualized shared decision-making remains important because several subgroup-specific estimates were imprecise, particularly in high-risk populations, indicating the need for further prospective validation.