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Clinical Question

Does my LVO patient need EVT?

Synthesises 15 trialsearly window, late window, large-core, and MeVO boundary

What does the guideline say?

  • §4.7.2· 2026

    In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1, presenting between 6 and 24 hours from onset of symptoms, with age <80 years, NIHSS score ≥6, prestroke mRS score 0 to 1, ASPECTS 3 to 5, and without significant mass effect on imaging, EVT is recommended to improve functional clinical outcomes and reduce mortality (COR 1, LOE A). In selected patients with AIS from anterior circulation proximal LVO of the ICA or M1 presenting within 6 hours from onset of symptoms, with age <80 years, NIHSS score ≥6, prestroke mRS 0 to 1, ASPECTS 0 to 2, and without significant mass effect on imaging, EVT is reasonable to improve functional clinical outcomes and reduce mortality (COR 2a, LOE B-R).

    Source: 2026 AHA/ASA Guideline · §4.7.2 (Anterior-circulation EVT eligibility, including large-core)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 15

MR CLEAN2015
First positive EVT trial. Thrombectomy benefit in proximal LVO.
+13 / 100NNT 7 (mRS 0–2 secondary)
ESCAPE2015
Small-core LVO thrombectomy raised independence to 53% vs 29%; mortality cut from 19% to 10%.
+24 / 100NNT 4.2 (mRS 0–2 secondary)
EXTEND-IA2015
Perfusion-selected EVT after tPA raised independence from 40% to 71%.
+31 / 100NNT ~3 (mRS 0–2 secondary)
SWIFT PRIME2015
Solitaire EVT after IV tPA raised independence from 35% to 60% in anterior LVO ≤6 h.
+25 / 100cOR 2.63 (1.57–4.40)
REVASCAT2015
Solitaire EVT ≤8 h raised independence from 28% to 44% in anterior LVO.
+16 / 100cOR 1.7 (1.05–2.8)
THRACE2016
Bridging EVT after IV tPA raised independence from 42% to 53% in proximal LVO ≤5 h.
NNT 9OR 1.55 (1.05–2.30)
DEFUSE-32018
Perfusion-selected thrombectomy at 6–16 h triples functional independence (45% vs 17%).
+28 / 100NNT 3.6 (mRS 0–2)
DAWN2018
Thrombectomy to 24 h with clinical–core mismatch: 49% vs 13% independence, NNT 2.8.
+36 / 100NNT 2.8
RESCUE-Japan LIMIT2022
EVT for ASPECTS 3-5 LVO improves 90-day mRS 0-3 (31% vs 13%).
NNT 5RR 2.43 (1.35-4.37)
LASTE2024
Large-core EVT (ASPECTS ≤5) shifted median mRS from 6 to 4 and cut mortality 55%→36%.
−19.4 pp mortalitygOR 1.63 (1.29–2.06)
TENSION2023
Large-core EVT (ASPECTS 3–5) by NCCT shifted median mRS 5→4; mortality 51%→40%.
SuperiorcOR 2.58 (1.60–4.15)
SELECT-22023
EVT for anterior LVO with large ischemic core (ASPECTS 3–5 or core ≥50 mL) within 24 h shifts mRS toward less disability.
+13 pp mRS 0–2gOR 1.51
ANGEL-ASPECT2023
EVT improves ordinal mRS shift in broader large-core anterior LVO (ASPECTS 3–5 or core 70–100 mL).
gOR 1.37gOR 1.37 (P=0.004)
ESCAPE-MeVO2025
Routine EVT for medium-vessel occlusion shows no functional benefit and higher sICH (5.4% vs 2.2%).
No benefitaRR 0.95
DISTAL2025
EVT for medium/distal vessel occlusion did not improve outcome and trended toward harm.
NeutralaOR 0.90

Related questions

Should I do EVT for large-core stroke (low ASPECTS)?

five positive RCTs (2022–2024) reversing the small-core-only EVT paradigm

Perfusion imaging or non-contrast CT for late-window selection?

evolution from CT-perfusion / MRI mismatch (DAWN, DEFUSE-3) to plain-CT and MRI ASPECTS selection (RESCUE-Japan LIMIT, LASTE, SELECT2, ANGEL-ASPECT)

Direct thrombectomy or bridging with IV thrombolysis first?

EVT-eligible LVO: skip the IVT or bridge? Six RCTs across China, Japan, Europe, and multinational

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