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Stroke, Jul 06 2026, | https://doi.org/10.1161/STROKEAHA.126.055374
Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS
Hokyu Kim 1, Wi-Sun Ryu 2, Manabu Inoue 3, Leonard Sunwoo 4, Kyusik Kang 5, Jae Guk Kim 6, Soo Joo Lee 6, Jae-Kwan Cha 7, Tai Hwan Park 8, Jeong-Yoon Lee 9, Kyungbok Lee 9, Doo Hyuk Kwon 10, Jun Lee 10, Hong-Kyun Park 11, Keun-Sik Hong 11, Minwoo Lee 12, Mi Sun Oh 12, Kyung-Ho Yu 12, Dong-Seok Gwak 13, Dong-Eog Kim 13, Hyunsoo Kim 14, Joon-Tae Kim 14, Joong-Goo Kim 15, Jay Chol Choi 15, Wook-Joo Kim 16, Jee Hyun Kwon 16, Kyu Sun Yum 17, Dong-Ick Shin 17, Jeong-Ho Hong 18, Sung-Il Sohn 18, Sang-Hwa Lee 19, Chulho Kim 19, Hae-Bong Jeong 20, Kwang-Yeol Park 20, Keon-Joo Lee 1, Chi Kyung Kim 1, Jihoon Kang 21, Jun Yup Kim 21, Hee-Joon Bae 21, Beom-Joon Kim 21
1Department of Neurology, Korea University Guro Hospital, Seoul (Hokyu Kim, K.-J.L., C.K.K.).
2Artificial Intelligence Research Center, JLK Inc, Seoul, Korea (W.-S.R.).
3Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.).
4Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (L.S.).
5Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea (K.K.).
6Department of Neurology, Eulji University School of Medicine, Daejeon Eulji Medical Center, Korea (J.G.K., S.J.L.).
7Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C.).
8Department of Neurology, Seoul Medical Center, Korea (T.H.P.).
9Department of Neurology, Soonchunhyang University Seoul Hospital, Korea (J.-Y.L., K.L.).
10Department of Neurology, Yeungnam University Medical Center, Daegu, Korea (D.H.K., J.L.).
11Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (H.-K.P., K.-S.H.).
12Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (M.L., M.S.O., K.-H.Y.).
13Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-S.G., D.-E.K.).
14Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea (Hyunsoo Kim, J.-T.K.).
15Department of Neurology, Jeju National University Hospital, Korea (J.-G.K., J.C.C.).
16Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Korea (W.-J.K., J.H.K.).
17Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (K.S.Y., D.-I.S.).
18Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea (J.-H.H., S.-I.S.).
19Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Korea (S.-H.L., C.K.).
20Department of Neurology, Chung-Ang University Hospital, Seoul, Korea (H.B.J., K.-Y.P.).
21Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (J.K., J.Y.K., H.-J.B., B.-J.K.).
Correspondence to: Wi-Sun Ryu, MD, PhD, Beom Joon Kim, MD, PhD
1Department of Neurology, Korea University Guro Hospital, Seoul (Hokyu Kim, K.-J.L., C.K.K.).
2Artificial Intelligence Research Center, JLK Inc, Seoul, Korea (W.-S.R.).
3Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.).
4Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (L.S.).
5Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea (K.K.).
6Department of Neurology, Eulji University School of Medicine, Daejeon Eulji Medical Center, Korea (J.G.K., S.J.L.).
7Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C.).
8Department of Neurology, Seoul Medical Center, Korea (T.H.P.).
9Department of Neurology, Soonchunhyang University Seoul Hospital, Korea (J.-Y.L., K.L.).
10Department of Neurology, Yeungnam University Medical Center, Daegu, Korea (D.H.K., J.L.).
11Department of Neurology, Inje University Ilsan Paik Hospital, Goyang, Korea (H.-K.P., K.-S.H.).
12Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (M.L., M.S.O., K.-H.Y.).
13Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-S.G., D.-E.K.).
14Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea (Hyunsoo Kim, J.-T.K.).
15Department of Neurology, Jeju National University Hospital, Korea (J.-G.K., J.C.C.).
16Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Korea (W.-J.K., J.H.K.).
17Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (K.S.Y., D.-I.S.).
18Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea (J.-H.H., S.-I.S.).
19Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Korea (S.-H.L., C.K.).
20Department of Neurology, Chung-Ang University Hospital, Seoul, Korea (H.B.J., K.-Y.P.).
21Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea. (J.K., J.Y.K., H.-J.B., B.-J.K.).
Correspondence to: Wi-Sun Ryu, MD, PhD, Beom Joon Kim, MD, PhD
Abstract
Background: Recent trials established the efficacy of thrombectomy for large-core stroke by utilizing the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) as a pragmatic tool. However, whether this topographical scoring captures the therapeutic ceiling, or the upper threshold of infarct volume where the benefit of reperfusion diminishes, remains unclear.
Methods: Leveraging a nationwide multicenter registry in Korea (2022-2024), we compared the prognostic value of quantitative volumetry and ASPECTS in thrombectomy-treated patients. We analyzed discordance between ASPECTS and volumetry derived from diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography. The primary outcome was poor functional outcome (90-day modified Rankin Scale score 5-6). To estimate treatment effects across specific volume spectra, we conducted target trial emulations that stratified causal estimates by volumetric thresholds, with the ordinal 90-day modified Rankin Scale score shift as the primary outcome.
Results: Among 552 patients, the mean age was 70.4±12.6 years, and 319 (57.8%) were men. Patients classified as large core by ASPECTS but not by diffusion-weighted imaging volumetry (ASPECTS-only large core) had poor outcome proportions comparable to the both small-core group (11.8% versus 11.7%), with no excess risk after adjustment. Conversely, volumetric confirmation of large core across diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography consistently predicted poor prognosis regardless of ASPECTS (adjusted odds ratio, 6.92 [95% CI, 2.58-19.34] for the diffusion-weighted imaging-only large-core group). In the target trial emulations, the overall benefit of thrombectomy was attenuated (common odds ratio, 0.56 [95% CI, 0.31-1.03]). Stratified analyses delineated a therapeutic ceiling, with benefit in the 50 to 110 mL range (common odds ratio, 0.38 [95% CI, 0.15-0.97]) disappearing in extensive infarctions >110 mL.
Conclusions: Quantitative volumetry provided better prognostic discrimination and identified ≥110 mL as a therapeutic ceiling where the benefit of thrombectomy becomes negligible. These findings advocate integrating volumetric thresholds into patient selection to minimize futile reperfusion and prioritize safety, serving as a critical refinement to current topographical scoring.
Methods: Leveraging a nationwide multicenter registry in Korea (2022-2024), we compared the prognostic value of quantitative volumetry and ASPECTS in thrombectomy-treated patients. We analyzed discordance between ASPECTS and volumetry derived from diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography. The primary outcome was poor functional outcome (90-day modified Rankin Scale score 5-6). To estimate treatment effects across specific volume spectra, we conducted target trial emulations that stratified causal estimates by volumetric thresholds, with the ordinal 90-day modified Rankin Scale score shift as the primary outcome.
Results: Among 552 patients, the mean age was 70.4±12.6 years, and 319 (57.8%) were men. Patients classified as large core by ASPECTS but not by diffusion-weighted imaging volumetry (ASPECTS-only large core) had poor outcome proportions comparable to the both small-core group (11.8% versus 11.7%), with no excess risk after adjustment. Conversely, volumetric confirmation of large core across diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography consistently predicted poor prognosis regardless of ASPECTS (adjusted odds ratio, 6.92 [95% CI, 2.58-19.34] for the diffusion-weighted imaging-only large-core group). In the target trial emulations, the overall benefit of thrombectomy was attenuated (common odds ratio, 0.56 [95% CI, 0.31-1.03]). Stratified analyses delineated a therapeutic ceiling, with benefit in the 50 to 110 mL range (common odds ratio, 0.38 [95% CI, 0.15-0.97]) disappearing in extensive infarctions >110 mL.
Conclusions: Quantitative volumetry provided better prognostic discrimination and identified ≥110 mL as a therapeutic ceiling where the benefit of thrombectomy becomes negligible. These findings advocate integrating volumetric thresholds into patient selection to minimize futile reperfusion and prioritize safety, serving as a critical refinement to current topographical scoring.
논문정보
- Research article
- 2026년 07월 (BRIC 등록일 2026-07-08)
- 국내 연구진
- 의약학 > 신경의학
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