Quantitative Infarct Volumetry Outperforms ASPECTS in Large-Core Stroke: Study

The investigation examined the imaging and clinical data on patients who underwent acute thrombectomy in an emergency setting for a period of several years between 2022 and 2024. Researchers carefully studied the structural discrepancy between ASPECTS scores based on regular CT images and automatically obtained volumetric parameters measured simultaneously on diffusion-weighted imaging (DWI), computed tomography perfusion (CTP), and conventional noncontrast computed tomography (NCCT).

The main outcome criterion in the predictive models was poor neurological function 90 days after stroke onset (modified Rankin Scale score from 5 to 6). To estimate the exact causal effect of treatment for particular volume values, the statistical team devised advanced emulation of a target trial with stratification of the estimates of the intervention according to volumetric cut-offs and global score change on the ordinal 90-day modified Rankin Scale.

Key findings:

• The nationwide validation study of neuro-interventional procedures was able to process and analyze data in terms of the baseline sample consisting of 552 patients.
• Mapped participants showed a mean age of 70.4 ± 12.6 years with predominance among males, making up 319 people or 57.8% of the entire sample.
• The patients, categorized as having a large core infarction based on ASPECTS criteria alone without volumetry of diffusion-weighted imaging, had low percentages of poor 90-day functional outcome at 11.8% that was almost identical to the true volumetric small core baseline of 11.7%.
• Inconsistently large core infarct volume, as confirmed by DWI, CTP, and NCCT, irrespective of high ASPECTS score, predicted poor clinical outcomes with an astonishing adjusted odds ratio of 6.92 (95% CI, 2.58–19.34) for patients with large cores defined by DWI only.
• Regarding the global target trial emulation models, the efficacy of mechanical thrombectomy treatment seemed to be reduced with a common odds ratio of 0.56 (95% CI, 0.31–1.03).
• Stratified target analysis confirmed the robust clinical benefit of clot retrieval therapy in an intermediate core volume of 50 to 110 mL range with a remarkable common odds ratio of 0.38 (95% CI, 0.15–0.97).

In summary, volumetric quantification offered more accurate discrimination and recognized ischemic volumes of 110 mL or higher as a threshold at which the benefits of thrombectomy therapy would be too minimal. The results support the inclusion of volumetric thresholds within the selection process in order to avoid futile reperfusion, thus ensuring safety, thereby representing a necessary improvement on the present topographical classification.

Reference:

Kim, H., Ryu, W.-S., Inoue, M., Sunwoo, L., Kang, K., Kim, J. G., Lee, S. J., Cha, J.-K., Park, T. H., Lee, J.-Y., Lee, K., Kwon, D. H., Lee, J., Park, H.-K., Hong, K.-S., Lee, M., Oh, M. S., Yu, K.-H., Gwak, D.-S., … Kim, B.-J. (2026). Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS. Stroke. https://doi.org/10.1161/strokeaha.126.055374