Eur Stroke J. 2026 Jun 2;11(6):aakag068. doi: 10.1093/esj/aakag068.
ABSTRACT
INTRODUCTION: The optimal imaging modality for selecting stroke patients for revascularisation in the extended window remains uncertain. The VESTA study compared simple (non-contrast CT + CTA) vs advanced imaging (including perfusion) in the extended window in terms of clinical outcomes, mortality and safety.
PATIENTS AND METHODS: This multicentre cohort study included 1262 stroke patients (last seen well 6-24 h, NIHSS ≥ 6) from the Catalan Stroke Registry (2019-2021). A central core lab re-evaluated images, and blinded investigators assessed 90-day functional outcomes. Inverse probability weighting (IPW) and multivariable methods were applied.
RESULTS: Median age was 76 years, NIHSS 12 and 48% were women. Simple imaging was used in 44% (n = 550), advanced in 56% (n = 712). Simple imaging had higher rates of no arterial occlusion (49% vs 37%, P = .006) and slightly lower endovascular treatment rates (36% vs 40%, P = .117). Time metrics were similar. In the IPW analysis, (advanced imaging as reference), simple imaging showed numerically worse point estimates across all outcomes, although most differences did not reach statistical significance: a worse mRS shift (adjusted odds ratio [aOR] 1.17 [95% CI, 0.96-1.43]; P = .11), a lower good functional outcome (mRS 0-2; aOR 0.83 [0.66-1.06]; P = .13), a higher mortality (aOR 1.20 [0.91-1.58]; P = .20), more frequent sICH (aOR 1.25 [0.61, 2.57]; P = .55) and a higher risk of any ICH (aOR 1.57 [1.00-2.47]; P = .05).
DISCUSSION: In moderate-to-severe stroke (NIHSS ≥ 6) within 6-24 h, simple imaging did not show a statistically significant difference vs advanced imaging for guiding stroke treatment. However, advanced imaging may improve patient selection for reperfusion and reduce haemorrhagic risk.
TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov under NCT05299034.
PMID:42308555 | DOI:10.1093/esj/aakag068
