Background A low baseline Alberta Stroke Programme Early CT Score (ASPECTS) is strongly associated with low rates of favorable outcome in patients with acute stroke. Objective To evaluate the efficacy and safety of revascularization therapy in patient with ASPECTS ≤5 in anterior circulation infarct. Methods We retrospectively analyzed 108 consecutive patients presenting low ASPECTS on diffusion-weighted imaging. Sixty patients were treated by mechanical thrombectomy, including 34 patients who received simultaneously intravenous thrombolysis. A control group of 48 patients not eligible for reperfusion therapy gave us a perspective on the natural history. Clinical outcome was evaluated at 90 days using the modified Rankin Scale (mRS) score. Hemicraniectomy after malignant infarction, mortality, and symptomatic intracranial haemorrhage (sICH) were also reported. Results Thrombolysis in Cerebral Infarction 2b-3 was assessed in 75% of treated patients. Reperfusion therapy led to significantly reduced disability (mRS score 0-2) at 90 days compared with the control group (30% vs 2.1%, p<0.001), hemicraniectomy (3.3% vs 22.9%, p=0.002), and death at 90 days (25% vs 47.9%, p=0.01). The sICH level was similar in treated patients and in the control group (p=0.78). Patients aged ≤70 years in the thrombectomy group had a significantly better clinical outcome than older patients (37.5% vs 10%, p=0.02), regardless of baseline characteristics or recanalization rate. Conclusions In patients with acute stroke in the anterior circulation and ASPECTS ≤5 revascularization therapy contributes to a favorable clinical outcome at 90 days, especially in patients younger than 70 years. InTROduCTIOnThe infarct volume at baseline is a strong and independent predictor of clinical outcome at day 90 1 and a critical determinant in patients treated with reperfusion therapies.2 Similarly, SAMURAI recombinant tissue plasminogen activator registry demonstrated that Alberta Stroke Programme Early CT Score (ASPECTS) ≤4 on diffusion-weighted imaging (DWI) was related to death at 3 months and ≤5 to symptomatic intracranial haemorrhage (sICH) within 36 hours. 3In 2015, several major randomized trials [4][5][6][7][8] proved that mechanical thrombectomy combined with IV thrombolysis (IVT) was better than IVT alone in the treatment of stroke with large vessel occlusion. The primary end point of these studies focused on disability reduction at 3 months, with modified Rankin Scale (mRS) score ≤2 ranging from 33% to 72% 7 in the thrombectomy arm with a consistent increase in the absolute value. To achieve these results, patient selection based on imaging was mandatory, excluding patients with a large infarction core. In the meta-analysis of the HERMES collaborators, 9 low baseline ASPECTS is strongly associated with low rates of favorable outcome.Unfortunately, real-world patients are not always the ideal 'trial' candidates for thrombectomy. Therefore, neurologists and interventional neuroradiologists are confronted daily with the decision to treat o...

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