Stroke Prognostication Obeys the Same Rules as Real Estate: Location, Location, Location!

In patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO), baseline ischemic core extent is one of the main criteria needed before a decision is made for mechanical thrombectomy (MT).1 The measurement method and the thresholds depend on the time from symptom onset. According to the selection criteria used in most positive MT trials within 6 to 12 hours after onset,2 it is currently recommended to offer MT to patients with stroke within 6 hours from onset if their Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is ≥6.1 More recent trials for patients with stroke with an unknown onset or a late onset (i.e., >6 hours) have also shown benefits of MT if the core infarct volume was below a certain threshold.3,4 Both of these algorithms imply that, ischemic lesions being irreversible, the initial infarct core can only remain the same or grow bigger, and a large initial infarct can only lead to a final infarct that will be at least as large. Final infarct volume is ultimately what shows the extent of brain lesions, and its size has been shown to be correlated with the clinical outcome.5

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