ImportanceRecently, 6 randomized clinical trials—RESCUE-Japan-LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism—Japan Large Ischemic Core Trial), ANGEL-ASPECT (Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct), SELECT2 (Trial of Endovascular Thrombectomy for Large Ischemic Strokes), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), TENSION (Endovascular Thrombectomy for Acute Ischemic Stroke With Established Large Infarct), and LASTE (Large Stroke Therapy Evaluation)—have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for the treatment of patients with ischemic stroke, anterior-circulation large vessel occlusions, and large areas of ischemic changes defined as an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 5 or less. Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.ObservationsIn this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.Conclusions and RelevanceRecent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel–occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. Future research to better identify patients likely to meaningfully respond to EVT is needed to further optimize the stroke triage process and health care resource utilization.

中文翻译：

---

大缺血核心患者的血管内卒中血栓切除术


重要性最近，6 项随机临床试验——RESCUE-Japan-LIMIT（脑超急性栓塞血管内挽救恢复——日本大型缺血核心试验）、ANGEL-ASSPECT（急性缺血性中风伴大面积梗死的血管内治疗试验）、SELECT2（大缺血性中风血管内血栓切除术试验）、TESLA（血栓切除术用于大前循环缺血性中风的紧急挽救）、TENSION（已确定的急性缺血性中风血管内血栓切除术Large Infarct） 和 LASTE（大型中风治疗评估）——已经结束了他们对血管内血栓切除术 （EVT） 治疗缺血性中风、前循环大血管闭塞和大面积缺血性改变患者的有效性和安全性的研究定义为艾伯塔省中风计划早期计算机断层扫描评分 （ASPECTS） 为 5 或更低。总体而言，结果似乎是积极的，6 项试验中有 5 项达到了其主要疗效终点，1 项试验差点错过。然而，关于如何解释这些试验结果并将其纳入常规临床实践，仍然存在问题。观察在对已发表试验的叙述性回顾和分析中，确定了可用临床数据的重要细微差别，并强调了挥之不去的不确定性的重要领域，包括 EVT 对治疗窗口晚期 ASPECTS 评分低的患者和核心体积大的患者的疗效和安全性。还强调了先进的神经影像学模式（如灌注和磁共振成像）在为 ASPECTS 评分低的特定患者做出 EVT 治疗决策时可能发挥的重要作用。结论和相关性最近的试验数据提供了强有力的证据表明，EVT 对中风发作后 6 小时内就诊的前部大血管闭塞中风和 ASPECTS 评分低的患者是安全有效的。然而，尽管接受了 EVT 治疗，患者的预后往往仍然很差。EVT 对中风发作超过 6 小时的 ASPECTS 评分低患者的有效性和安全性仍不确定，目前的试验数据似乎太稀缺，无法证明在此延长的时间窗口内放弃高级中风成像是合理的。此外，EVT 对核心体积大 （100 mL 或更大） 或 M2 闭塞 （即大脑中动脉第二段闭塞） 患者的疗效和安全性仍不确定。需要进一步的研究来更好地识别可能对 EVT 产生有意义反应的患者，以进一步优化中风分流过程和医疗保健资源利用。