RAPID-LC: rapid evidence-to-practice uptake of large core thrombectomy across a stroke consortium.

BACKGROUND

Recent landmark trials, including SELECT2, ANGEL-ASPECT, and RESCUE-Japan LIMIT, demonstrated the benefit of endovascular thrombectomy (EVT) in patients with large ischemic cores, primarily among those with ASPECTS 3-5, with limited representation of ASPECTS 0-2. However, real-world adoption across the full spectrum of low ASPECTS remains uncertain.

METHODS

We conducted a retrospective, multicenter, before-and-after cohort study comparing the pre-publication (July-December 2021, n = 150) and post-publication (January-June 2024, n = 195) periods. Adults presenting within 24 h of large vessel occlusion stroke with large cores (ASPECTS ≤ 5 or CT core > 70 mL) were included. The primary outcome was EVT utilization (receipt of thrombectomy). Secondary outcomes were 30- and 90-day modified Rankin Scale (mRS) and mortality. Safety outcomes included symptomatic intracranial hemorrhage and procedural complications. Multivariable logistic regression identified independent predictors of receiving EVT, adjusting for clinical and imaging variables.

RESULTS

A total of 345 patients were included (median age 70 years, 52% male). EVT utilization increased from 42% (63/150) in 2021 to 60.5% (118/195) in 2024. In multivariable analysis, the year 2024 was the strongest independent predictor of receiving EVT (adjusted OR 3.11; p < 0.001). ASPECTS score was the dominant imaging predictor of receiving EVT (adjusted OR 7.11 for ASPECTS 3-5 vs 0-2). EVT use in patients with ASPECTS 0-2 increased from 4.3 to 32.5%. Among treated cohorts, mortality increased non-significantly from 27 to 33.9% (p = 0.340). Functional outcomes at 30 and 90 days did not differ significantly between cohorts.

CONCLUSION

Publication of large core thrombectomy trials was associated with substantial increases in endovascular thrombectomy use in large-core stroke, including among patients with very low ASPECTS, with a non-significant increase in symptomatic intracranial hemorrhage and a decline in favorable functional outcomes. Clinician adherence to baseline severity considerations (ASPECTS, age, and premorbid function) appears appropriate. These findings demonstrate the safe and rapid translation of evidence into practice and highlight the importance of standardized implementation strategies to optimize patient outcomes.