Abstract TP72: Large Core Trials – Game Changing for Stroke Care or falling on deaf ears?

Introduction: After publication of Large core trials that offered evidence that endovascular therapies (EVT) was more beneficial versus medical management for acute ischemic strokes with large vessel occlusion (LVO) in carefully selected patients. We aimed to see how the treatment paradigm has evolved following the publications of the large core trials at different institutions. Hypothesis: After Large Core Trials, we suspect moderate increase in EVT/MT for large core ischemic infarcts with LVO based on prior reported data of 20% more increment. Methods: This study was done as a retrospective review with IRB approval for chart review. Included population was defined those with ASPECTS 5 or less with LVO within 24 hours of presentation presenting to one of the 4 included Comprehensive stroke centers (CSC’s). Using Viz.ai automated software data, 3-month sampling of LVO alerted scans between the time period of 11/1/2021 to 1/31/2022 (before trials) and 11/1/2023 to 1/31/2024 (post Trials) at 5 CSC’s. Non contrast head CT was reviewed to select large core strokes defined as ASPECTS 5 or less, and evaluated whether or not these patients were taken for EVT/MT, and the primary reason for exclusion from EVT. Primary outcome was defined as percentage of patients taken for EVT in above population. Results: 3-month sample of pre-large core data showed that 4/17 (23.5%) of patients with large ischemic core (ASPECTS 5 or less) had EVT. Of these 4, one was taken as a TESLA enrollment as we were a participating site for TESLA. Post large-core 3-month sampling revealed an improvement of 5/11 (45.4%) EVT rate for large core patients. Overall average discharge MRS (DC MRS) for large-core patients who received EVT with TICI 2B or greater revascularization was 3. Large core patients who did not receive EVT had average DC MRS of 5.1. The primary stated reason for not taking patients with large ischemic core for EVT pre and post large core trials was ‘large-core’ in every reviewed case. Conclusion: Given the favorable data seen in the recent Large-Core trials, the patients will probably benefit from EVT, however even in clinical trial enrolling site majority of Large core patients are still being taken for EVT. Some barriers to changing the treatment paradigm may include: slow adaptation of new data/trials, concern for symptomatic ICH, concern for futility, and recognition of the more favorable patient selection in terms of age/MRS in the Large-Core trials.