How Do Patient Outcomes in Mechanical Thrombectomy for Large-Core Stroke Vary Based on Neuroimaging Modalities Used for Patient Selection? A Multicenter Multinational Study

Omar Alwakaa¹, Rahim Abo Kasem², Felipe Ramirez-Velandia¹, Aryan Wadhwa¹, Kimberly Han¹, Michael R Levitt³, Ali Alaraj⁴, Pascal Jabbour⁵, Joon-Tae Kim⁶, Brian Howard⁷, Ali Alawieh⁷, Stacey Quintero Wolfe⁸, Robert M Starke⁹, Marios-Nikos Psychogios¹⁰, Amir Shaban¹¹, Nitin Goyal¹², Justin Dye¹³, Mohamad Ezzeldin¹⁴, Shinichi Yoshimura¹⁵, Daniel Sconzo¹, Jean Filo¹, Samuel Pettersson¹, David Fiorella¹⁶, Omar Tanweer¹⁷, Daniele G Romano¹⁸, Pedro Navia¹⁹, Hugo Cuellar²⁰, Isabel Fragata²¹, Adam Polifka²², Justin Mascitelli²³, Joshua Osbun²⁴, Fazeel Siddiqui²⁵, Mark Moss²⁶, Kaustubh Limaye²⁷, Maxim Mokin²⁸, Charles Matouk²⁹, Min S Park³⁰, Waleed Brinjikji³¹, Ergun Daglioglu³², Richard Williamson Jr³³, David J Altschul³⁴, Ilko Maier³⁵, Roberto Crosa³⁶, Benjamin Gory³⁷, Ramesh Grandhi³⁸, Alexandra Paul³⁹, Peter Kan⁴⁰, Walter Casagrande⁴¹, Shakeel Chowdhry⁴², Michael F Stiefel⁴³, Ansaar Rai⁴⁴, Alejandro M Spiotta², Philipp Taussky¹, Christopher S Ogilvy¹, Justin H Granstein⁴⁵

Affiliations

¹ Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02115, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
³ Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA.
⁴ Neurosurgery, University of Illinois Chicago, Chicago, IL, USA.
⁵ Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁶ Chonnam National University Medical School, Gwangju, Korea.
⁷ Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
⁸ Neurosurgery, Wake Forest School of Medicine, Winston Salem, NC, USA.
⁹ Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA.
¹⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹¹ The University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
¹² Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA.
¹³ Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA.
¹⁴ Department of Clinical Neuroscience, University of Houston, HCA Houston Healthcare Kingwood, Kingwood, TX, USA.
¹⁵ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁶ Neurological Surgery, Stony Brook Hospital, Stony Brook, NY, USA.
¹⁷ Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
¹⁸ Neuroradiology, University Hospital 'San Giovanni Di Dio E Ruggi d'Aragona', Salerno, Italy.
¹⁹ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
²⁰ LSUHSC, Shreveport, LA, USA.
²¹ Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
²² Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
²³ Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
²⁴ Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA.
²⁵ Department of Neuroscience, University of Michigan Health-West, Wyoming, MI, USA.
²⁶ Washington Regional Medical Center, Fayetteville, AR, USA.
²⁷ Department of Neurology, Indiana University, Bloomington, IN, USA.
²⁸ Department of Neurosurgery, University of South Florida, Tampa, FL, USA.
²⁹ Yale University, New Haven, CT, USA.
³⁰ Neurosurgery, University of Virginia, Charlottesville, VA, USA.
³¹ Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA.
³² Department of Neurosurgery, Health Science University, Ankara Bilkent City Hospital, Ankara, Turkey.
³³ Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA.
³⁴ Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
³⁵ University Medicine Goettingen, Goettingen, Germany.
³⁶ Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
³⁷ Department of Diagnostic and Interventional Neuroradiology, INSERM U947, University Hospital of Nancy, Nancy, France.
³⁸ Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA.
³⁹ Department of Neurosurgery, Albany Medical Center, Albany, NY, USA.
⁴⁰ Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.
⁴¹ Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina.
⁴² NorthShore University HealthSystem, Evanston, IL, USA.
⁴³ Department of Neurosurgery, Piedmont Atlanta Hospital, Atlanta, GA, USA.
⁴⁴ Department of Neuroradiology, West Virginia University Hospitals, Morgantown, WV, USA.
⁴⁵ Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02115, USA. jgranste@bidmc.harvard.edu.

PMID: 40900221
DOI: 10.1007/s12975-025-01378-6

How Do Patient Outcomes in Mechanical Thrombectomy for Large-Core Stroke Vary Based on Neuroimaging Modalities Used for Patient Selection? A Multicenter Multinational Study

Omar Alwakaa et al. Transl Stroke Res. 2025.

. 2025 Sep 3.

doi: 10.1007/s12975-025-01378-6. Online ahead of print.

Authors

Affiliations

¹ Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02115, USA.
² Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.
³ Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA.
⁴ Neurosurgery, University of Illinois Chicago, Chicago, IL, USA.
⁵ Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
⁶ Chonnam National University Medical School, Gwangju, Korea.
⁷ Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA.
⁸ Neurosurgery, Wake Forest School of Medicine, Winston Salem, NC, USA.
⁹ Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA.
¹⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹¹ The University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
¹² Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA.
¹³ Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA.
¹⁴ Department of Clinical Neuroscience, University of Houston, HCA Houston Healthcare Kingwood, Kingwood, TX, USA.
¹⁵ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
¹⁶ Neurological Surgery, Stony Brook Hospital, Stony Brook, NY, USA.
¹⁷ Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
¹⁸ Neuroradiology, University Hospital 'San Giovanni Di Dio E Ruggi d'Aragona', Salerno, Italy.
¹⁹ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
²⁰ LSUHSC, Shreveport, LA, USA.
²¹ Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
²² Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
²³ Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
²⁴ Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA.
²⁵ Department of Neuroscience, University of Michigan Health-West, Wyoming, MI, USA.
²⁶ Washington Regional Medical Center, Fayetteville, AR, USA.
²⁷ Department of Neurology, Indiana University, Bloomington, IN, USA.
²⁸ Department of Neurosurgery, University of South Florida, Tampa, FL, USA.
²⁹ Yale University, New Haven, CT, USA.
³⁰ Neurosurgery, University of Virginia, Charlottesville, VA, USA.
³¹ Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA.
³² Department of Neurosurgery, Health Science University, Ankara Bilkent City Hospital, Ankara, Turkey.
³³ Department of Neurosurgery, Allegheny Health Network, Pittsburgh, PA, USA.
³⁴ Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
³⁵ University Medicine Goettingen, Goettingen, Germany.
³⁶ Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
³⁷ Department of Diagnostic and Interventional Neuroradiology, INSERM U947, University Hospital of Nancy, Nancy, France.
³⁸ Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA.
³⁹ Department of Neurosurgery, Albany Medical Center, Albany, NY, USA.
⁴⁰ Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.
⁴¹ Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina.
⁴² NorthShore University HealthSystem, Evanston, IL, USA.
⁴³ Department of Neurosurgery, Piedmont Atlanta Hospital, Atlanta, GA, USA.
⁴⁴ Department of Neuroradiology, West Virginia University Hospitals, Morgantown, WV, USA.
⁴⁵ Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, MA, 02115, USA. jgranste@bidmc.harvard.edu.

PMID: 40900221
DOI: 10.1007/s12975-025-01378-6

Abstract

The role of different imaging modalities-non-contrast CT (NCCT), CT perfusion (CTP), and diffusion-weighted imaging (DWI)-in selecting patients with large-core stroke for endovascular thrombectomy (EVT) is a subject of ongoing debate. This study aims to determine whether patients with large-core acute ischemic stroke (AIS) undergoing EVT triaged with CTP or DWI in addition to NCCT had different clinical outcomes compared to those only triaged with NCCT. We queried the Stroke Thrombectomy and Aneurysm Registry (STAR) for patients enrolled between 2014 and 2023 who presented with anterior-circulation AIS and large ischemic core (ASPECTS < 6) who underwent EVT in 41 stroke centers in the USA, Europe, Asia, and South America. Patients were stratified by the imaging used before EVT. Propensity score matching (PSM) was used to compare balanced cohorts of patients with NCCT vs CTP and NCCT vs DWI. The primary outcome was a favorable 90-day functional status (mRS 0-3). Secondary outcomes included intracerebral hemorrhage (ICH) rates, symptomatic ICH (sICH), and successful/complete recanalization, as determined by mTICI score. A total of 403 patients were included, 121 were selected with NCCT alone, 227 with CTP, and 55 with DWI. Before PSM, 90-day mRS 0-3, successful reperfusion mTICI ≥ 2B, and sICH rates were similar across the three imaging modalities. mTICI-2C or greater rates were highest in DWI (50.9%; p < 0.01), followed by NCCT (41.3%) and CTP (27.8%). Patients selected with CTP had the highest ICH incidence (44.1%; p < 0.01). After 1:1 PSM, 104 pairs of NCCT vs CTP and 36 pairs of NCCT vs DWI were compared. There were no significant differences in any procedural or functional outcome measure between the matched groups, including mTICI ≥ 2C recanalization, 90-day mRS 0-3, ICH rates, and sICH rates. In patients with anterior large-vessel occlusion AIS with low ASPECTS, we found that selecting patients for EVT based on NCCT or employing advanced imaging to elucidate collaterals, infarct volume, and ischemic penumbra does not alter procedural or patient outcomes. NCCT alone may be sufficient to select patients for EVT in this patient population, especially in settings with limited resources.

Keywords: Alberta Stroke Program Early Computed Tomography (ASPECT) score; Endovascular thrombectomy; Large-vessel occlusion; Propensity score matching; Stroke; Successful recanalization.

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Conflict of interest statement

Declarations. Conflict of Interest: Dr Ilko L Maier: speakers’honoraria from Pfizer and Bristol-Myers Squibb. Dr Robert M Starke: RMS research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. RMS has an unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. Dr Marios-Nikos Psychogios: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Grants for the DISTAL trial from Stryker Neurovascular Inc., Phenox GmbH, Penumbra Inc. and Rapid Medical Inc., Sponsor-PI SPINNERS trial (Funded by a Siemens Healthineers AG Grant), Research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. Dr. S. Yoshimura: received lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. Dr Hugo Cuellar: Consultant for Medtronic and Microvention. Dr Daniele G. Romano: Consultant for Penumbra, Balt, Microvention, Phenox. Dr Omar Tanweer: Consulting Agreements: Viz.AI, Inc., Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Q’apel Inc, Steinberg Foundation. Dr. Justin. Mascitelli: Bee Foundation, Joe Niekro Foundation, Mizuho. Stryker, Imperative Care Site. Dr. Charles Matouk: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. Speaker for Penumbra and Silk Road Medical. Contact PI for NIH Grant R21NS128641. Dr. Min S. Park: Consultant for Medtronic. Dr Michael R Levitt: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers, Metis Innovative, and Genomadix; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. Dr Waleed Brinjikji: Holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. Dr Richard Williamson: Consultant for Medtronic, Stryker, and Synaptive Medical. Dr. Pedro Navia: Consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. Dr Peter Kan: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens. Consultant for Imperative Care and Stryker Neurovascular. Stock ownership in Vena Medical. Dr Shakeel A Chowdhry: Consultant and proctor for Medtronic and Microvention. Dr Mohammad Ezzeldin: Consultant for Viz.ai and Imperative care. Investments in Galaxy Therapeutics. Dr David J Altschul: Consultant for MicroVention, Stryker, and Cerenovus. Dr Ramesh Grandhi: Consultant for Balt Neurovascular, Cerenovus, Medtronic Neurovascular, Rapid Medical, and Stryker Neurovascular. Dr Alejandro M Spiotta: Consultant for Penumbra, Terumo, RapidAI, Cerenovus. Dr Ali Alaraj: Consultant for Cerenovus. Data Sharing Statement: The relevant anonymized patient-level data are available on reasonable request from the authors. Consent to Participate: The study protocol was reviewed and approved by the Institutional Review Board. Following institutional guidelines, all protected health information was removed, and individual patient consent was not required in the analysis of the case series. Competing Interests: The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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How Do Patient Outcomes in Mechanical Thrombectomy for Large-Core Stroke Vary Based on Neuroimaging Modalities Used for Patient Selection? A Multicenter Multinational Study

Affiliations

How Do Patient Outcomes in Mechanical Thrombectomy for Large-Core Stroke Vary Based on Neuroimaging Modalities Used for Patient Selection? A Multicenter Multinational Study

Authors

Affiliations

Abstract

Conflict of interest statement

References

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