Come One, Come All: Streamlining Patient Selection and Imaging Protocols for Stroke Thrombectomy

Learning Objectives:

1. To review current literature regarding large vessel occlusion (LVO) thrombectomy in patients with large core infarcts (LCI).


2. To discuss a single center experience in eliminating advanced imaging in the triage of LCI.


3. To discuss functional outcomes and complications in patients undergoing thrombectomy for LCI.

Background: The window for stroke thrombectomy has traditionally been less than 6 hours from symptom onset, but studies like DAWN and DEFUSE demonstrate the utility of performing thrombectomy for LVO within 6-24 hours of symptom onset coupled with information from perfusion imaging. Recent studies like SELECT 2, RESCUE-LIMIT JAPAN, and ANGEL-ASPECT have shown that performing an LVO thrombectomy in LCI (ASPECTS score < 3) has a low risk of spontaneous intracerebral hemorrhage (sICH) and a return to function for almost 1 in 9 patients. We have streamlined our approach to thrombectomy in patients with LCI or those outside the traditional 6-hour window by eliminating advanced imaging and triaging patients mostly based on non-contrast Computed Tomography (CT)/CT Angiography findings and functional status.

Clinical Findings/Procedure Details: Since the completion of SELECT 2, our practice has expanded patient selection for LVO (M1 segment of the middle cerebral artery or internal carotid artery (ICA) terminus) thrombectomy to include patients with last known well time up to 24 hours, ASPECTS score > 3, and Modified Rankin Scale (mRS) 0-2. We have performed 74 thrombectomies, of which 21 were for LCI (ASPECTS 4 or higher). Given the expanded criteria for thrombectomy, our practice has moved away from obtaining CT Perfusion or Magnetic Resonance imaging in patients within the 24-hour window, as the delineation of salvageable penumbra has become less of a factor in performing thrombectomy. Intervening within 24 hours of symptom onset in patients with reasonable baseline functionality as determined by mRS is now deemed sufficient, affording us more efficient decision-making and increased procedure volumes. While our results align with the reported safety profiles and complication rates (0/21 major complications or sICH), we have not seen a similar return to function as the 1 in 7 or 1 in 9 that some of the newer trials suggest.

Conclusion and/or Teaching Points: With the completion of stroke thrombectomy trials for LCI, our practice has seen decreased utilization of advanced imaging, as most patients presenting within 24 hours of symptom onset meet criteria for thrombectomy. This abstract will review how our practice has streamlined stroke triage and patient selection based on new data and how our results compare to those of larger RCT.