Endovascular versus medical treatment in large-core stroke within 24 hours in Vietnam

BACKGROUND: The efficacy and safety of endovascular treatment (EVT) in large ischemic core stroke remain understudied in developing countries. METHODS: We conducted a multicenter prospective cohort study in Vietnam from August 2023 to September 2024, screening consecutive cases of patients with large vessel occlusion treated within 24 hours. Patients with large ischemic core (ASPECTS ≤5) and large vessel occlusion within 24 hours were included. The primary outcome was independent ambulation, defined as an mRS score of 0-3, at 90 days. Secondary outcomes included ordinal mRS shift, successful reperfusion, symptomatic intracranial hemorrhage (sICH), as defined by SITS-MOST, and the 90-day mortality rate. Propensity-score overlap weighting was performed to adjust for baseline imbalances. RESULTS: Among 491 patients (36.9% women, median age 64 years), 403 (82.1%) underwent endovascular treatment (EVT), while 88 (17.9%) received best medical treatment (BMT) alone. After propensity score overlap weighting was estimated and applied, 385 EVT and 79 BMT patients were included in a balanced cohort. EVT was associated with improved functional outcome rate of mRS 0-3 (50.2% vs 26.8%, OR = 2.75, 95% CI = 1.42-5.33; p = 0.003), and a favorable shift in mRS score (3.00 [interquartile range (IQR), 2-5] vs 5.00 [IQR, 3-6], OR = 2.61, 95% CI = 1.49-4.58; p < 0.001). Successful reperfusion (mTICI 2b-3) was achieved in 93.7% of patients who underwent EVT. EVT was also associated with lower 90-day mortality (15.0% vs 38.2%, OR = 0.29, 95% CI = 0.15-0.56; p < 0.001). However, any intracranial hemorrhage was significantly more frequent in the EVT group (75.6% vs 37.3%, OR = 5.21, 95% CI = 2.51-10.82; p < 0.001). Notably, sICH occurred numerically more often with EVT (9.4%) than with BMT (5.1%), but this difference was not statistically significant (OR = 1.94, 95% CI = 0.41-9.13; p = 0.402). CONCLUSION: EVT was associated with improved functional outcomes and reduced mortality compared to BMT in patients with large ischemic core stroke presenting within 24 hours of symptom onset, but had more intracranial hemorrhages. These findings support the potential benefit of EVT for patients with large ischemic cores in low- and middle-income countries; however, further validation is warranted given residual confounding by indication and incomplete follow-up imaging.