ENDOVASCULAR THROMBECTOMY BEYOND CONVENTIONAL IMAGING LIMITS: LARGE-CORE AND POSTERIOR-CIRCULATION STROKE IN THE ERA OF TISSUE- BASED SELECTION

Аннотация

Background. Endovascular  thrombectomy  has  moved  beyond  the  conventional  paradigm  that restricted treatment to patients with small infarct cores, favorable perfusion mismatch, anterior- circulation occlusion, and narrow time windows. Randomized trials now support thrombectomy in selected large-core anterior-circulation stroke and moderate-to-severe basilar artery occlusion, making tissue viability, eloquent anatomy, collateral support, and clinical severity more important than time alone. 
Materials   and   methods.   Randomized   trials,   individual-patient-data   meta-analyses,   practice guidelines,  imaging  studies,  and  procedural  investigations  published  through  July  2026  were synthesized. Evidence was organized by infarct extent, imaging modality, time window, occlusion territory, neurological severity, reperfusion quality, hemorrhagic risk, and expected disability shift. Results. RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TENSION, LASTE, and the 2026 ATLAS analysis demonstrate an overall functional and survival benefit of thrombectomy in large-core stroke, although uncertainty persists for core volumes of 150 mL or greater, extensive edema, very low ASPECTS,   and   delayed   presentation.   ATTENTION,   BAOCHE,   and   VERITAS   support thrombectomy for basilar or dominant vertebral occlusion with moderate-to-severe deficits and limited irreversible brainstem injury. Imaging should identify hemorrhage, occlusion, infarct distribution, collateral  circulation,  edema,  and  procedural  feasibility  without  creating  avoidable  delays.  The proposed TISSUE-LVO model separates  prognostic severity from  treatment  responsiveness  and emphasizes rapid, technically effective, complication-conscious reperfusion selection. 
Conclusion. Large-core or posterior-circulation involvement should no longer constitute an automatic exclusion. Treatment decisions should integrate tissue injury, anatomical eloquence, clinical severity, collateral reserve, procedural probability, and patient-centered outcome goals.
Keywords: endovascular thrombectomy; large ischemic core; large-vessel occlusion; ASPECTS; computed tomography perfusion; basilar artery occlusion; posterior-circulation stroke; tissue-based selection; reperfusion; ischemic penumbra.