Evaluate real-world clinical and safety outcomes of Endovascular Therapy (EVT) for large core acute ischemic strokes (AIS) with large vessel occlusions (LVO) in an Indian population and compare them with pooled data from recent randomized controlled trials (RCTs).

Large core AIS have largely been excluded from EVT studies due to perceived higher risks of hemorrhage and poorer functional outcomes. Three recent RCTs (RESCUE-JAPAN LIMIT, ANGEL-ASPECTS, SELECT-2) suggest that EVT for LVO in these strokes yields improved functional outcomes compared to medical management alone, despite increased rate of hemorrhagic transformation, but not of symptomatic ICH (sICH). Real-world outcomes of this in Indian patients remain underexplored.

Retrospective analysis of a prospective database of seven years of EVT in anterior circulation AIS patients at a tertiary care center was done. Patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3-5 were included. Efficacy outcome was 90-days modified Rankin Scale (mRS) scores and safety outcomes were rates of sICH and mortality. Statistical analysis was done using IBM Statistical Package for Social Sciences software-version 25.

The study included 25 patients of AIS with ASPECTS 3-5 who underwent EVT. Mean age was 52.9 ± 14.3 years with 13 (52%) males. Median NIHSS at presentation was 17 (IQR 13.25-21.75); median ASPECTS was 5 (IQR 4-5). Successful recanalization, determined by modified Thrombolysis in Cerebral Infarction (mTICI) score was 92%. Rates of sICH were higher than the pooled data of the three RCTs: 16 % vs 4.72% (p 0.013), but similar rates of good functional outcomes i.e. 90-days mRS 0-3 (36% vs 40.5%, p 0.651) and mortality rates (36% vs 26.8%, p 0.311) were achieved in this cohort.

Our results provide updated real-world evidence of outcomes of EVT in large core ischemic infarcts. Efficacy and mortality outcomes were similar to RCTs despite higher rates of sICH.