Journal article
Endovascular Thrombectomy for Extracranial Internal Carotid Artery Occlusions With Large Ischemic Strokes: Insights From the SELECT2 Trial
Neurology, Vol.104(4), e210269
02/25/2025
DOI: 10.1212/WNL.0000000000210269
PMID: 39869840
Abstract
Background and Objectives
Although previous trials have established the efficacy and safety of endovascular thrombectomy (EVT) in large ischemic core strokes, most of them excluded patients with extracranial internal carotid artery (e-ICA) occlusion. We aimed to compare outcomes in patients with e-ICA occlusion and large ischemic core infarcts treated with EVT vs medical management (MM).
Methods
This was a secondary analysis of the SELECT2 trial, a randomized controlled trial conducted at 31 international sites. Adult patients with proximal intracranial anterior circulation large ischemic strokes, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3–5 on noncontrast CT or ischemic core ≥50 mL on CT-perfusion/magnetic resonance-diffusion imaging, and concomitant e-ICA occlusion were selected. The primary outcomes were the distribution of modified Rankin Scale (mRS) score at 90-day follow-up and symptomatic intracranial hemorrhage (sICH).
Results
Among 352 enrolled patients, 62 (17.6%) with e-ICA occlusions were included. Of those 62 patients, 37 received EVT (median [interquartile range (IQR)] age, 65 [58–71] years; 15 women [38.5%]) and 25 received MM (median [IQR] age, 66 [61–71] years; 7 women [28%]). ASPECTS (EVT: 5 [3–5] vs MM: 5 [4–5]) and ischemic core volume (EVT: 100 [69–134] mL vs MM: 103 [78–135] mL) were similar between groups. The successful reperfusion rate with EVT was 64.9%. Patients receiving EVT demonstrated significantly better functional outcomes (adjusted generalized odds ratio 2.51; 95% CI 1.43–4.39; p = 0.001) and a higher proportion of patients achieving 90-day independent ambulation (EVT: 37.8% vs MM: 8%; adjusted relative ratio [aRR] 4.58; 95% CI 1.18–17.79; p = 0.037) and functional independence (EVT: 21.6% vs MM: 8%; aRR 2.16; 95% CI 0.53–8.83; p = 0.285). Furthermore, no heterogeneity of EVT benefit was observed by the presence or absence of e-ICA occlusion (p-interaction = 0.248). There were no sICH or parenchymal hemorrhage type 2 events in either group, and mortality was similar in the 2 groups (aRR 0.75; 95% CI 0.39–1.45; p = 0.388).
Discussion
Among patients with e-ICA occlusions and large ischemic core stroke, EVT was associated with better functional outcomes without significant safety concerns when compared with MM. Our findings suggest that EVT in these patients is beneficial, while the optimal treatment of the extracranial carotid occlusion remains unclear.
Trial Registration Information
Name of the trial: SELECT2 trial. Registration number: ClinicalTrials.gov Identifier: NCT03876457. Date of registration submission: August 3, 2019. Date of first patient enrollment: November 10, 2019.
Classification of Evidence
This study provides Class II evidence that for patients with large core acute ischemic stroke and concomitant e-ICA occlusion, EVT is associated with better functional outcome at 90 days compared with MM alone.
Details
- Title: Subtitle
- Endovascular Thrombectomy for Extracranial Internal Carotid Artery Occlusions With Large Ischemic Strokes: Insights From the SELECT2 Trial
- Creators
- Santiago Ortega-Gutierrez - Department of Neurosurgery and Radiology, andNirav Vora - Riverside Methodist HospitalAaron Rodriguez-Calienes - Universidad Científica del SurRicardo A Hanel - Baptist Medical Center JacksonvilleDeep Pujara - University Hospitals of ClevelandAmin Aghaebrahim - Baptist Medical Center JacksonvilleClark Sitton - The University of Texas Health Science Center at HoustonFrances Colgan - Christchurch HospitalMilagros Galecio-Castillo - University of Iowa, NeurologyMaria Angeles de Miquel - Bellvitge University HospitalAmeer E Hassan - Valley Baptist Medical CenterChirag D Gandhi - Westchester Medical CenterMichael G Abraham - University of KansasFawaz Al-Mufti - Westchester Medical CenterMichael Chen - Rush University Medical CenterJordi Blasco - Hospital Clínic de BarcelonaSpiros Blackburn - The University of Texas Health Science Center at HoustonLuis San Román Manzanera - Hospital Clínic de BarcelonaScott E Kasner - University of PennsylvaniaNabeel A Herial - Thomas Jefferson University HospitalHeena Olalde - University of IowaNathan W Manning - Liverpool HospitalMalik Ghannam - University of Iowa, NeurologyAndrew Cheung - Liverpool HospitalOsman Kozak - Thomas Jefferson University HospitalMuhammad S Hussain - Cleveland ClinicEnrique C Leira - University of Iowa Hospitals and ClinicsBernard Yan - Royal Melbourne HospitalMario Martínez-Galdámez - Hospital Clínico Universitario de ValladolidPeter J Mitchell - Royal Melbourne HospitalAmir Shaban - University of Iowa, NeurologyKoji Ebersole - University of KansasJenny P Tsai - Cleveland ClinicGabor Toth - Cleveland ClinicMichael Gooch - Thomas Jefferson University HospitalHannah Roeder - University of Iowa, NeurologyJulie C Gudenkauf - University of Iowa, NeurologyDaniel GibsonRonald Budzik - Riverside Methodist HospitalDaniel H SahleinKrishna AmuluruMohammad Ammar Abdulrazzak - The Neurological InstituteKelsey Duncan - Department of Neurosurgery, andDana Defta - Department of Neurosurgery, andFaris Shaker - University of KansasFaisal Al-Shaibi - Case Western Reserve UniversityAbhishek Ray - University Hospitals of ClevelandJeffrey Sunshine - University Hospitals of ClevelandYin C Hu - University Hospitals of ClevelandJan Karl Burkhardt - University of PennsylvaniaOsman Mir - Department of Interventional Neurology, Texas Stroke Institute, DallasBader Alenzi - King Fahad Specialist HospitalTareq Kass-Hout - University of ChicagoRishi Gupta - WellStar Health SystemStavropoula I Tjoumakaris - Thomas Jefferson University HospitalPascal M Jabbour - Thomas Jefferson University HospitalThanh N Nguyen - Boston Medical CenterJohanna Therese Fifi - Icahn School of Medicine at Mount SinaiVitor Mendes Pereira - St. Michael's HospitalNicholas Bambakidis - University Hospitals of ClevelandMichael D Hill - University of CalgaryJames C Grotta - Memorial HermannMarc Ribo - Vall d'Hebron Hospital UniversitariBruce C V CampbellEdgar A Samaniego - Department of Neurosurgery and Radiology, andAmrou Sarraj - University Hospitals of Cleveland
- Resource Type
- Journal article
- Publication Details
- Neurology, Vol.104(4), e210269
- Publisher
- LIPPINCOTT WILLIAMS & WILKINS; PHILADELPHIA
- DOI
- 10.1212/WNL.0000000000210269
- PMID
- 39869840
- ISSN
- 0028-3878
- eISSN
- 1526-632X
- Language
- English
- Date published
- 02/25/2025
- Academic Unit
- Neurology; Radiology; Epidemiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984780352302771
Metrics
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