Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee.

Background: Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS.
Methods: A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.
Results: The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR).
Conclusions: The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
Competing Interests: Competing interests: The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health (“NIH”). SWH is an ex officio member of the SNIS Board of Directors. His research is supported by NIH (R01CA194533, R42CA265316, R01EB012031). He has consulting agreements with Medtronic, Imperative, and Cerenovus and an ownership interest in Filtro. His institution has contract and grant support from Siemens, Stryker Neurovascular, and Route 92. CMS has contract or research support from Penumbra, Medtronic, MIVI, Cerenovus, Stryker, Balt, and ownership interest in NTI. None of the other authors have relevant disclosures. JKB serves as a consultant for Stryker, Microvention, Cerenovus, Balt, Medtronic, Q’Apel Medical, Longeviti Neuro Solutions, and Siemens Healthineers. DR consults for Q’Apel, Penumbra, and Phenox. MRA is a member of the SNIS Board of Directors and a member of the editorial board for the JNIS. His research is supported by NIH (R21 DC016097-01A1, R56HL149124-01) and DOD (PR201091). He has consulting agreements with Medtronic, Stryker, Microvention, and VS3 Medical and ownership interest in VS3 Medical. His institution has contract and grant support from VS3 Medical.
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