Endovascular Treatment for eXtra-Large Ischemic Stroke

Several randomized trials have shown that endovascular thrombectomy improve functional outcomes in acute ischemic stroke patients with large vessel occlusion. Recently, six randomized controlled trials demonstrated the efficacy and safety of endovascular thrombectomy for large infarct patients (defined as Alberta Stroke Program Early Computed Tomography Score [ASPECTS] ≥3 or infarct core <100ml). Patients with extra-large infarct core (volume greater than 100 mL, ASPECTS score of 0 to 2) accounted for a small proportion of these trials. Therefore, the role of endovascular thrombectomy in patients with extra-large ischemic burden is still unclear. That is to say, exactly where the lower limit of endovascular thrombectomy is unknown. The XL STROKE-2 randomized trial is aiming to investigate the efficacy and safety of mechanical thrombectomy in acute extra-large ischemic stroke patients with large vessel occlusion.

Inclusion criteria

• Age 18 years or older, and modified Rankin scale score = 0 or 1 in patients 80 years or older;
• Acute ischemic stroke within 6 hours from last known well to randomization, or with negative MRI-FLAIR (no change on FLAIR sequence and presence of infarct on MRI-DWI) if > 6 hours or unknown last known well time;
• Occlusion of the internal carotid artery, M1 or M2 segment of the middle cerebral artery confirmed by CTA/MRA/DSA;
• Baseline ASPECTS score of 0-2 or infarct core volume ≥100ml;
• The patient or patient's representative signs a written informed consent form.

Exclusion criteria

• CT or MR evidence of hemorrhage;
• Evidence of mass effect with ventricular effacement, midline shift or herniation on baseline imaging;
• Vessel tortuosity where it is expected that the thrombectomy device will not be able to reach the occlusion site or result in unstable access;
• History of bleeding disorders, severe heart, liver or kidney disease, or sepsis;
• Currently participating in another investigational drug study;
• Any terminal illness with life expectancy less than 6 months.