Large Core Thrombectomy: Feasibility of Simplified Protocol in Resource‐Limited Settings

BACKGROUND Several trials have demonstrated the benefits of endovascular thrombectomy (EVT) for large‐core strokes (Alberta Stroke Program Early CT [Computed Tomography] Score <6). However, its effectiveness in lower‐middle‐income countries with resource‐limited settings remains uncertain. This study evaluated the feasibility of EVT for large‐core strokes using a simplified imaging protocol with noncontrast CT and CT angiography in a resource‐constrained environment. METHODS We conducted a prospective, single‐center, observational study at Da Nang Hospital, Vietnam (May 2023–May 2024). Patients with anterior circulation large‐vessel occlusion strokes, Alberta Stroke Program Early CT Score <6 on noncontrast CT, admission National Institutes of Health Stroke Scale score ≥6, and EVT within 24 hours were included. The primary outcome was the modified Rankin Scale score at 90 days. Functional independence was defined as modified Rankin Scale score 0–2 and ambulatory independence as 0–3. Safety outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Post‐hoc indirect comparisons of ambulatory independence and mortality were made against the Large Stroke Therapy Evaluation EVT arm and the best medical treatment cohorts from 6 published “large core” randomized controlled trials. RESULTS Among 157 EVT‐treated patients, 52 (33.1%) had Alberta Stroke Program Early CT Score <6. Median age was 62.5 years, and 57.7% were male. Median onset‐to‐hospital time was 4.1 hours, admission National Institutes of Health Stroke Scale score15, and initial Alberta Stroke Program Early CT Score was 4. Successful reperfusion (modified Treatment in Cerebral Infarction≥2b) was 78.9%. At 90 days, the median modified Rankin Scale score was 3.5. Functional and ambulatory independence were 23.1% and 50%, respectively. Symptomatic intracranial hemorrhage occurred in 9.6%, mortality was 25%. Successful reperfusion was the only independent predictor of ambulatory independence (odds ratio [OR], 14.7; 95% CI, 1.6–134). Indirect comparisons showed higher ambulatory independence in our cohort compared with the Large Stroke Therapy Evaluation EVT arm (50.0% versus 33.5%, P = 0.033) and the pooled best medical treatment cohort from 6 published randomized controlled trials (50.0% versus 19.89%, P <0.001), with no significant mortality difference. CONCLUSIONS EVT is feasible for patients with large‐core stroke in lower‐income countries using a simplified noncontrast CT ‐CTA protocol. Successful reperfusion is a key determinant of improved outcomes. CLINICAL TRIAL REGISTRATION INFORMATION This study is a substudy of the multicenter PROMISE (Predictors of Good Outcomes in Thrombectomy for Large Infarct Core Stroke Evaluation) cohort, registered on ClinicalTrials.gov (NCT06016348, https://clinicaltrials.gov/study/NCT06016348 ), using data from patients enrolled at Da Nang Hospital.

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