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Clear Benefit of Thrombectomy in Large-Core Stroke
BARCELONA, Spain — A new individual patient-level data meta-analysis has shown “overwhelming benefit” of endovascular thrombectomy (EVT) in a wide spectrum of patients with large-core strokes.
The ATLAS meta-analysis showed consistent improvements(NOT GOOD ENOUGH!) in functional independence and independent ambulation and reduced mortality with EVT compared with best medical management alone.
The treatment benefit of EVT was maintained across key clinical and imaging subgroups, regardless of age, sex, clinical severity, time to treatment, stroke size, and mismatch profile.
Rates of symptomatic intracerebral hemorrhage (ICH) and neurological worsening were higher with EVT; however, these risks did not outweigh the overall clinical benefit.
“These results establish the superiority of endovascular thrombectomy over best medical management in patients with large core stroke who account for around one fifth of those with large vessel occlusion stroke”, study investigator, Amrou Sarraj, MD, professor of neurology at Case Western Reserve University School of Medicine, Cleveland, told Medscape Medical News.“This is powerful and overwhelming evidence of the superiority of thrombectomy over medical management, extending to the vast majority of patients with large-core strokes caused by large vessel occlusion”, he added.
Sarraj noted that patients with such poor prognostic profiles have historically not been treated. However, since results from recent trials were published, some guidelines have been updated to recommend thrombectomy for large-core strokes. Still, some interventionalists and professional organizations remain cautious, particularly regarding certain subgroups.
“These new data will help solidify the evidence and open doors to treatment for more patients, giving them the opportunity for improved outcomes,” Sarraj added.
The findings were presented on October 22 at 17th World Stroke Congress (WSC) 2025.
Expanded EVT Eligibility
Endovascular clot removal was first shown to benefit patients with large-vessel occlusion who presented within 6 hours of stroke onset. A subsequent wave of trials demonstrated that this approach also benefits patients presenting up to 24 hours after onset, provided imaging shows a small infarct core and salvageable brain tissue.
The current meta-analysis focuses on a third group of patients, those with large-core strokes presenting up to 24 hours after onset. This patient population was previously considered unlikely to benefit from reperfusion therapy.
The Analysis of mechanical Thrombectomy for LArge core ischemic Stroke (ATLAS) meta-analysis included individual patient data from six randomized trials — RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2, TENSION, TESLA, and LASTE — encompassing a total of 1886 patients with acute anterior circulation stroke who presented within 24 hours of onset.
A large ischemic core was defined as an Alberta Stroke Program Early CT Score (ASPECTS), a 10-point grading system used to assess the extent of early ischemic damage, with lower scores indicating worse prognosis — of < 6, or a core volume of ≥ 50 mL.
The primary outcome — 90-day modified Rankin Scale (mRS) score, assessed by shift analysis — showed a clear benefit for EVT (adjusted odds ratio, 1.63; 95% CI, 1.42-1.87; P < .001).
Favorable functional outcomes were also strongly positive. An mRS score of 0-2 was achieved in 9.5% of EVT patients compared with 7.5% of control individuals (adjusted risk ratio [aRR], 2.61; P < .001).
An mRS score of 0-3 was achieved in 36.6% of patients in the EVT group vs 19.8% of those in the control group (aRR, 1.95; P < .001). Mortality was also reduced in EVT patients — 31% vs 37% (aRR, 0.82; P = .018).
Symptomatic ICH and neurological worsening were higher with EVT. Symptomatic ICH occurred in 5.5% of patients in the EVT group vs 2.7% of those in the control group (aRR, 2.02; P = .017). Neurological worsening occurred in 22% vs 17% of patients (aRR, 1.27; P = .123).
Despite this, Sarraj said the net clinical benefit was positive in terms of lower mortality and improved mRS scores.
Practice Changing
Sarraj noted that the six randomized trials of EVT in large-core stroke have all shown benefit, though they differed in imaging modalities, eligibility criteria, geographic regions, and outcome measures.
He acknowledged the substantial heterogeneity among the trials — a feature that supports the generalizability of findings but also highlights the need for a deeper understanding of treatment effects overall and across subgroups defined by stroke severity, size, ASPECTS score, and core volume. He said that pooling individual patient data from all trials will allow for more detailed insights than any single study can provide.
“Practice is starting to change, but there has still been some uncertainty about benefit in certain subgroups, for example, in patients with particularly large cores, those with very low ASPECTS scores, and those presenting very late. Now we have undisputed evidence that all of these patients benefit from endovascular thrombectomy,” Sarraj said.
He noted that the meta-analysis demonstrated benefit of EVT across both early (0-6 hour) and late (6-24 hour) time windows, in older and younger patients alike, and regardless of hemisphere, sex, or mismatch profile. Benefit was also observed in patients with very low ASPECTS scores (0-2) in the early window and in those with large core volumes of up to 150 mL.
“So I would say that the vast majority of patients with large-score strokes should now be treated with thrombectomy if possible,” he said.
Benefit Even Without Mismatch
The benefit of EVT was maintained in patients with very low ASPECTS scores in the early time window, and in patients with large core volumes up to 150mL, Sarraj noted.
“The only groups where we haven’t been able to show benefit are those patients with ASPECTS scores of 0-2 who present beyond 6 hours, and those with a stroke core volume of 150 ml or more, but these are very small numbers of patients.”
The meta-analysis also showed benefit regardless of mismatch profile identified with sophisticated imaging techniques. This refers to the amount of tissue that is at risk from the stroke but still presumed salvageable compared with the size of the ischemic core tissue affected.
Endovascular therapy was previously thought to benefit only patients with a large mismatch and substantial areas of salvageable tissue, but these results suggest that is not the case.
“The results are challenging a long-held belief that patients without mismatch are beyond help and will be harmed by thrombectomy and that we have to see evidence of salvageable tissue to use this treatment. Some of the individual trials in large core stroke have also suggested this, but now we have more definite evidence from a larger group,” Sarraj said.
He added that while some clinicians may still use advanced imaging to assess mismatch profiles for prognostic purposes, he no longer considers this necessary for excluding patients — except in cases where the core volume exceeds 150 mL.
Clear Benefit
Commenting on the ATLAS meta-analysis for Medscape Medical News, Raul Nogueira, MD, professor of neurology and neurosurgery at University of Pittsburgh School of Medicine, Pittsburgh, said it was “very important data.”
He said the meta-analysis reinforces the benefits of EVT in this population and provides greater confidence in groups where uncertainty had persisted, including patients with very low ASPECTS scores and those with large core volumes of 100-150 mL.
Nogueira also emphasized that the meta-analysis demonstrated clear benefit of EVT even in patients without a mismatch group in which the value of intervention has been debated. He noted that emerging evidence supports a more nuanced view of stroke injury, suggesting it is not a simple matter of viable vs nonviable tissue.
“The core tissue is not alive or dead. There are actually shades of gray. It is not only the size of the core that matters but also whether the damage is early/immature or complete/mature. There can be islands of tissue within the core that may still be preserved and may still be able to be rescued. I think this is what we are seeing in these results.”
ATLAS meta-analysis did not receive any external funding. Sarraj reported receiving research funding from Stryker Neurovascular.
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