Owing to perceived poor outcomes and limited benefit from reperfusion therapies, acute stroke patients presenting with large infarct core on baseline imaging were consistently excluded from thrombolytic and endovascular therapy trials for the last two decades (1–10). Prioritizing finding an effective treatment for the majority of acute stroke patients has paved the way for the current standard-of-care, and improved survival and functional recovery for a vast number of individuals (11, 12). However, whether thrombolytic and endovascular therapies are safe and provide functional benefits in presence of large infarct cores is still unknown. As acute stroke research continues to expand the indication for both medical and endovascular therapies, management of acute stroke patients with large infarct core becomes the next frontier to explore (13–16).
Elucidating the best management of a recently established or evolving large infarct comes down to three key questions. First, what are the optimal imaging modalities and criteria to identify a “large core”? Second, are attempts at reducing the infarct core size via thrombolytic or endovascular reperfusion justified by their risk-benefit balance? And third, how can secondary injury and complications of acute large infarcts be minimized?
This review on the topic of acute strokes with large infarct core examines all three aspects. Koopman et al. present evidence that perfusion imaging is a reliable early biomarker to predict clinical outcome in this patient population. Yang et al. continue the discussion with evidence that patient age and perfusion profile may potentially define a ceiling to treatment benefits (17). To address this complexity of early outcome prediction, Chen et al. propose a model based on demographic and imaging biomarkers (18). As the discussion shifts to acute therapy, Hu et al. suggest a promising role for low-dose tirofiban (19). Meanwhile, Hassan et al. present data from the COMPLETE registry to reaffirm the importance of time in limiting infarct growth and improving clinical outcomes (20). DeHoff and Lau then round off our discussion with a review of medical management of cerebral edema resulting from large hemispheric infarcts (21).
The world of cerebrovascular medicine currently eagerly awaits the outcomes of randomized controlled trials on endovascular therapy for acute strokes with large infarct cores (22–24). While endovascular reperfusion may yet again promise the most effective treatment, the complexity of acute stroke patients presenting with large cores highlights the ongoing need for multi-faceted, collaborative research to optimize their outcomes. It is long overdue.
Statements
Author contributions
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
Conflict of interest
AS reports grant support from Stryker Neurovascular for the SELECT2 clinical trial, is a member of the speaker bureau and advisory board for Stryker Neurovascular and has received consultant fees from AstraZeneca. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Summary
Keywords
stroke, thrombectomy, large ischemic core, cerebrovascular disease, neuroimaging
Citation
Tsai JP, Schaafsma JD and Sarraj A (2023) Editorial: Management of acute stroke with large core. Front. Neurol. 14:1135886. doi: 10.3389/fneur.2023.1135886
Received
02 January 2023
Accepted
16 January 2023
Published
06 February 2023
Volume
14 - 2023
Edited and reviewed by
Jean-Claude Baron, University of Cambridge, United Kingdom
Updates
Copyright
© 2023 Tsai, Schaafsma and Sarraj.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jenny P. Tsai ✉ tsaij4@ccf.org
This article was submitted to Stroke, a section of the journal Frontiers in Neurology
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.