Limited data available: >80 years of age, mRS ≥2, no core-penumbra mismatch, ASPECTS 0-2, from LKW

All patients presenting with concern for stroke should undergo the following imaging:

• Non-contrast CT head
• MRI wake-up protocol when indicated ASPECTS measurement on CT or DWI-MRI
• CTA head and neck
• MRI wake-up protocol when indicated
• CTP when indicated
• ASPECTS measurement on CT or DWI-MRI

Endovascular thrombectomy (EVT) for acute ischemic stroke with anterior circulation large vessel occlusion (LVO)one of the most effective interventions in medicine with a number needed to treat (NNT) of 4 for functional independence at 90 days. Historically, large-core infarcts determined on both non-contrast computed tomography (CT) and CT perfusion have been excluded from EVT treatment based on concerns about futility, risk for ICH, and death. Recent studies (ANGEL-ASPECTS, RESCUE-Japan LIMIT, SELECT2, TENSION, TESLA, and LASTE) have demonstrated that patients with large ischemic core on basic imaging should not be excluded from this effective treatment. Patients with large core infarct have improved functional outcomes at 90 days with EVT, and do not have statistically significant increased risk for symptomatic ICH or death compared to medical management alone.

1. ASPECTS 6-10
   1. Should receive EVT when presenTIng <24 hours from LKW
2. ASPECTS 3-5
   1. Do not exclude from treatment with EVT when presenting <12 hours from LKW
   2. CTP if presenting >12 hours from LKW
      1. Should receive EVT if core infarct volume ≤125mL
      2. May be reasonable to proceed with EVT following discussion with family for core infarct >125mL
3. ASPECTS 0-2
   1. Do not exclude from treatment with EVT when presen ng <6 hours from LKW
   2. CTP if presenting >6 hours from LKW
      1. Should receive EVT if core infarct volume ≤125mL
      2. May be reasonable to proceed with EVT following discussion with family for core volume >125mL

Bendszus M, Fiehler J, Sub l F, et al. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. 2023;402(10414):1753-1763. doi:10.1016/S0140-6736(23)02032-9 (TENSION)

Costalat V, Jovin TG, Albucher JF, et al. Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size. N Engl J Med. 2024;390(18):1677-1689. doi:10.1056/NEJMoa2314063 (LASTE)

Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct. N Engl J Med. 2023;388(14):1272-1283. doi:10.1056/NEJMoa2213379 (ANGEL-ASPECTS)

Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published correc on appears in N Engl J Med. 2024 Jan 25;390(4):388]. N Engl J Med. 2023;388(14):1259-1271. doi:10.1056/NEJMoa2214403 (SELECT-2)

Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191 (RESCUE-Japan LIMIT)