Despite several effective strategies of stroke prevention, the stroke epidemic still constitutes the leading cause of permanent disability. The recent series of well-designed, convincingly-positive randomized controlled trials of endovascular thrombectomy in stroke patients with large vessel occlusion launched a paradigm shift and a new era in acute stroke management. The present review provides an overview of the technical aspects of the procedure, discusses patient selection criteria, summarizes the current evidence from randomized trials about its efficacy and safety, and explores its implications in the organization of acute stroke care.

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort (P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Background Recent advances in machine learning have enabled development of the automated Alberta Stroke Program Early CT Score (ASPECTS) prediction algorithms using non-contrast enhanced computed tomography (NCCT) scans. The applicability of automated ASPECTS in daily clinical practice is yet to be established. The objective of this meta-analysis was to directly compare the performance of automated and manual ASPECTS predictions in recognizing early stroke changes on NCCT. Methods The MEDLINE, Scopus, and Cochrane databases were searched. The last database search was performed on March 10, 2022. Studies reporting the diagnostic performance and validity of automated ASPECTS software compared with expert readers were included. The outcomes were the interobserver reliability of outputs between ASPECTS versus expert readings, experts versus reference standard, and ASPECTS versus reference standard by means of pooled Fisher’s Z transformation of the interclass correlation coefficients (ICCs). Results Eleven studies were included in the meta-analysis, involving 1976 patients. The meta-analyses showed good interobserver reliability between experts (ICC 0.72 (95% CI 0.63 to 0.79); p<0.001), moderate reliability in the correlation between automated and expert readings (ICC 0.54 (95% CI 0.40 to 0.67); p<0.001), good reliability between the total expert readings and the reference standard (ICC 0.62 (95% CI 0.52 to 0.71); p<0.001), and good reliability between the automated predictions and the reference standard (ICC 0.72 (95% CI 0.61 to 0.80); p<0.001). Conclusions Artificial intelligence-driven ASPECTS software has comparable or better performance than physicians in terms of recognizing early stroke changes on NCCT.