Objectives We investigated whether patients with large infarct and the presence or absence of perfusion mismatch are associated with endovascular treatment benefit. Methods This is a post‐hoc analysis of the Endovascular Therapy in Anterior Circulation Large Vessel Occlusion with a Large Infarct (ANGEL‐ASPECT) randomized trial, which enrolled patients within 24 hours of onset with ASPECTS 3 to 5 or ASPECTS 0 to 2 with an infarct core 70 to 100 ml. Mismatch ratio was defined as time‐to‐maximum (T max ) &gt;6 s cerebral volume/ischemic core volume, and mismatch volume was defined as T max &gt;6 s volume minus ischemic core volume. We divided patients into mismatch ratio ≥1.2 and mismatch volume ≥10 ml, and mismatch ratio ≥1.8 and mismatch volume ≥15 ml groups. The primary outcome was the 90‐day modified Rankin Scale score ordinal distribution. Safety outcomes were symptomatic intracranial hemorrhage and 90‐day mortality. Results There were 425 patients included. In both the mismatch ratio ≥1.2 and mismatch volume ≥10 ml (mismatch+, n = 395; mismatch−, n = 31) and mismatch ratio ≥1.8 and mismatch volume ≥15 ml groups (mismatch+, n = 346; mismatch−, n = 80), better 90‐day modified Rankin Scale outcomes were found in the endovascular treatment group compared with the MM group (4 [2–5] vs 4 [3–5], common odds ratio [cOR], 1.9, 95% confidence interval [CI] 1.3–2.7, p = 0.001; 4 [2–5] vs 4 [3–5], cOR, 1.9, 95% CI 1.3–2.8, p = 0.001, respectively), but not in patients without mismatch ratio ≥1.2 and mismatch volume ≥10 ml (5 [3–6] vs 5 [4–6], cOR, 1.2, 95% CI 0.3–4.1, p = 0.83), and mismatch ratio ≥1.8 and mismatch volume ≥15 ml (4 [3–6] vs 5 [3–6], cOR, 1.2, 95% CI 0.6–2.7, p = 0.60). However, no interaction effect was found in both subgroups ( p interaction &gt;0.10). Conclusion Endovascular treatment was more efficacious than MM in patients with mismatch profiles, but no treatment effect or interaction was noted in the no mismatch profile patients. However, the small sample size of patients with no mismatch may have underpowered our analysis. A pooled analysis of large core trials stratified by mismatch is warranted. ANN NEUROL 2024

Association of Mismatch Profiles and Clinical Outcome from Endovascular Therapy in Large Infarct: A Post‐Hoc Analysis of the <scp>ANGEL</scp>‐<scp>ASPECT</scp> Trial

Association of Mismatch Profiles and Clinical Outcome from Endovascular Therapy in Large Infarct: A Post‐Hoc Analysis of the ANGEL‐ASPECT Trial