Editorial: Management of acute stroke with large core

Abstract

Editorial on the Research Topic Management of acute stroke with large coreOwing to perceived poor outcomes and limited benefit from reperfusion therapies, acute stroke patients presenting with large infarct core on baseline imaging were consistently excluded from thrombolytic and endovascular therapy trials for the last two decades (1-10). Prioritizing finding an effective treatment for the majority of acute stroke patients has paved the way for the current standard-of-care, and improved survival and functional recovery for a vast number of individuals (11, 12). However, whether thrombolytic and endovascular therapies are safe and provide functional benefits in presence of large infarct cores is still unknown. As acute stroke research continues to expand the indication for both medical and endovascular therapies, management of acute stroke patients with large infarct core becomes the next frontier to explore (13-16).Elucidating the best management of a recently established or evolving large infarct comes down to three key questions. First, what are the optimal imaging modalities and criteria to identify a "large core"? Second, are attempts at reducing the infarct core size via thrombolytic or endovascular reperfusion justified by their risk-benefit balance? And third, how can secondary injury and complications of acute large infarcts be minimized?This review on the topic of acute strokes with large infarct core examines all three aspects. Koopman et al. present evidence that perfusion imaging is a reliable early biomarker to predict clinical outcome in this patient population. Yang et al. continue the discussion with evidence that patient age and perfusion profile may potentially define a ceiling to treatment benefits (17). To address this complexity of early outcome prediction, Chen et al. propose a model based on demographic and imaging biomarkers (18). As the discussion shifts to acute therapy, Hu et al. suggest a promising role for low-dose tirofiban (19). Meanwhile, Hassan et al. present data from the COMPLETE registry to reaffirm the importance of time in limiting infarct growth and improving clinical outcomes (20). DeHoff and Lau then round off our discussion with a review of medical management of cerebral edema resulting from large hemispheric infarcts (21).The world of cerebrovascular medicine currently eagerly awaits the outcomes of randomized controlled trials on endovascular therapy for acute strokes with large infarct cores (22)(23)(24). While endovascular reperfusion may yet again promise the most effective treatment, the complexity of acute stroke patients presenting with large cores highlights the ongoing need for multi-faceted, collaborative research to optimize their outcomes. It is long overdue.

CTP-Defined Large Core Is a Better Predictor of Poor Outcome for Endovascular Treatment Than ASPECTS-Defined Large Core

“…Optimal imaging modalities to identify large cores remains unclear 13,14 despite recent positive trials ubiquitously showing the efficacy of EVT. Patients in RESCUE JAPAN LIMITED trial (The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism–Japan Large Ischemic Core Trial) was selected with NCCT/DWI ASPECTS 3 to 5 while both NCCT ASPECTS and CTP were used in ANGEL ASPECT (Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core) and SELECT 2 (Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke).…”

“…Optimal imaging modalities to identify large cores remains unclear 13,14 despite recent positive trials ubiquitously showing the efficacy of EVT. Patients in RESCUE as the only trial solely using ASPECTS as entry criterion for subject recruitment so far, recapitulates the efficacy of EVT by showing improved functional outcome and lower mortality.…”