{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T15:24:31Z","timestamp":1787757871585,"version":"build-2784847793"},"reference-count":43,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","license":[{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Stroke"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>Recent trials established the efficacy of thrombectomy for large-core stroke by utilizing the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) as a pragmatic tool. However, whether this topographical scoring captures the therapeutic ceiling, or the upper threshold of infarct volume where the benefit of reperfusion diminishes, remains unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>Leveraging a nationwide multicenter registry in Korea (2022\u20132024), we compared the prognostic value of quantitative volumetry and ASPECTS in thrombectomy-treated patients. We analyzed discordance between ASPECTS and volumetry derived from diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography. The primary outcome was poor functional outcome (90-day modified Rankin Scale score 5\u20136). To estimate treatment effects across specific volume spectra, we conducted target trial emulations that stratified causal estimates by volumetric thresholds, with the ordinal 90-day modified Rankin Scale score shift as the primary outcome.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>Among 552 patients, the mean age was 70.4\u00b112.6 years, and 319 (57.8%) were men. Patients classified as large core by ASPECTS but not by diffusion-weighted imaging volumetry (ASPECTS-only large core) had poor outcome proportions comparable to the both small-core group (11.8% versus 11.7%), with no excess risk after adjustment. Conversely, volumetric confirmation of large core across diffusion-weighted imaging, computed tomography perfusion, and noncontrast computed tomography consistently predicted poor prognosis regardless of ASPECTS (adjusted odds ratio, 6.92 [95% CI, 2.58\u201319.34] for the diffusion-weighted imaging\u2013only large-core group). In the target trial emulations, the overall benefit of thrombectomy was attenuated (common odds ratio, 0.56 [95% CI, 0.31\u20131.03]). Stratified analyses delineated a therapeutic ceiling, with benefit in the 50 to 110 mL range (common odds ratio, 0.38 [95% CI, 0.15\u20130.97]) disappearing in extensive infarctions &gt;110 mL.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>Quantitative volumetry provided better prognostic discrimination and identified \u2265110 mL as a therapeutic ceiling where the benefit of thrombectomy becomes negligible. These findings advocate integrating volumetric thresholds into patient selection to minimize futile reperfusion and prioritize safety, serving as a critical refinement to current topographical scoring.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/strokeaha.126.055374","type":"journal-article","created":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T09:00:41Z","timestamp":1783328441000},"page":"2677-2686","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Defining the Therapeutic Ceiling of Endovascular Thrombectomy in Large-Core Stroke: Beyond the Limits of ASPECTS"],"prefix":"10.1161","volume":"57","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4409-5198","authenticated-orcid":true,"given":"Hokyu","family":"Kim","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2823-5253","authenticated-orcid":true,"given":"Wi-Sun","family":"Ryu","sequence":"additional","affiliation":[{"name":"Artificial Intelligence Research Center, JLK Inc, Seoul, Korea (W.-S.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5228-6643","authenticated-orcid":true,"given":"Manabu","family":"Inoue","sequence":"additional","affiliation":[{"name":"Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0374-8658","authenticated-orcid":true,"given":"Leonard","family":"Sunwoo","sequence":"additional","affiliation":[{"name":"Department of Radiology (L.S.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4021-4439","authenticated-orcid":true,"given":"Kyusik","family":"Kang","sequence":"additional","affiliation":[{"name":"Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea (K.K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1418-0033","authenticated-orcid":true,"given":"Jae Guk","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Neurology, Eulji University School of Medicine, Daejeon Eulji Medical Center, Korea (J.G.K., S.J.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8622-7000","authenticated-orcid":true,"given":"Soo Joo","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Neurology, Eulji University School of Medicine, Daejeon Eulji Medical Center, Korea (J.G.K., S.J.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1049-5196","authenticated-orcid":true,"given":"Jae-Kwan","family":"Cha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5148-1663","authenticated-orcid":true,"given":"Tai Hwan","family":"Park","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4297-1791","authenticated-orcid":true,"given":"Jeong-Yoon","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of 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