Journal article
Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles
JAMA : the journal of the American Medical Association, Vol.331(9), pp.750-763
03/05/2024
DOI: 10.1001/jama.2024.0572
PMCID: PMC10851143
PMID: 38324414
Abstract
Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain.
To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect.
An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022.
EVT vs MM.
Primary outcome was functional outcome-90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI.
Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled.
In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased.
ClinicalTrials.gov Identifier: NCT03876457.
Details
- Title: Subtitle
- Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles
- Creators
- Amrou Sarraj - University Hospitals of ClevelandAmeer E Hassan - Valley Baptist Medical CenterMichael G Abraham - University of Kansas Medical CenterSantiago Ortega-Gutierrez - University of IowaScott E Kasner - University of PennsylvaniaMuhammad Shazam Hussain - Cleveland ClinicMichael Chen - Rush University Medical CenterLeonid Churilov - University of MelbourneHannah Johns - Royal Melbourne HospitalClark W Sitton - The University of Texas Health Science Center at HoustonVignan Yogendrakumar - University of MelbourneFelix C Ng - University of MelbourneDeep K Pujara - University Hospitals of ClevelandSpiros Blackburn - The University of Texas Health Science Center at HoustonSophia Sundararajan - Case Western Reserve UniversityYin C Hu - University Hospitals of ClevelandNabeel A Herial - Thomas Jefferson University HospitalJuan F Arenillas - Universidad de ValladolidJenny P Tsai - Corewell Health Blodgett HospitalRonald F Budzik - Riverside Methodist HospitalWilliam J Hicks - Riverside Methodist HospitalOsman Kozak - Abington Memorial HospitalBernard Yan - Royal Melbourne HospitalDennis J Cordato - Liverpool HospitalNathan W Manning - Liverpool HospitalMark W Parsons - Liverpool HospitalAndrew Cheung - Liverpool HospitalRicardo A Hanel - Baptist Medical Center JacksonvilleAmin N Aghaebrahim - Baptist Medical Center JacksonvilleTeddy Y Wu - Christchurch HospitalPere Cardona Portela - Bellvitge University HospitalChirag D Gandhi - Westchester Medical CenterFawaz Al-Mufti - Westchester Medical CenterNatalia Pérez de la Ossa - Hospital Universitari Germans Trias i PujolJoanna D Schaafsma - Toronto Western HospitalJordi Blasco - Hospital Clínic de BarcelonaNavdeep Sangha - Kaiser PermanenteSteven Warach - The University of Texas at AustinTimothy J Kleinig - Royal Adelaide HospitalFaris Shaker - The University of Texas Health Science Center at HoustonFaisal Al Shaibi - University Hospitals of ClevelandGabor Toth - Cleveland ClinicMohammad A Abdulrazzak - Cleveland ClinicGagan Sharma - University of MelbourneAbhishek Ray - University Hospitals of ClevelandJeffrey Sunshine - University Hospitals of ClevelandAmanda Opaskar - University Hospitals of ClevelandKelsey R Duncan - University Hospitals of ClevelandWei Xiong - University Hospitals of ClevelandEdgar A Samaniego - University of IowaLaith Maali - University of Kansas Medical CenterColleen G Lechtenberg - University of Kansas Medical CenterArturo Renú - Hospital Clínic de BarcelonaNirav Vora - Riverside Methodist HospitalThanh Nguyen - Boston Medical CenterJohanna T Fifi - Icahn School of Medicine at Mount SinaiStavropoula I Tjoumakaris - Thomas Jefferson University HospitalPascal Jabbour - Thomas Jefferson University HospitalGeorgios Tsivgoulis - National and Kapodistrian University of AthensVitor Mendes Pereira - St Michael's HospitalMaarten G Lansberg - Stanford UniversityMichael DeGeorgia - University Hospitals of ClevelandCathy A Sila - Case Western Reserve UniversityNicholas Bambakidis - University Hospitals of ClevelandMichael D Hill - University of CalgaryStephen M Davis - Royal Melbourne HospitalLawrence Wechsler - Hospital of the University of PennsylvaniaJames C Grotta - Memorial HermannMarc Ribo - Vall d'Hebron Hospital UniversitariGreg W Albers - Stanford UniversityBruce C Campbell - Royal Melbourne HospitalSELECT2 Investigators
- Resource Type
- Journal article
- Publication Details
- JAMA : the journal of the American Medical Association, Vol.331(9), pp.750-763
- Publisher
- American Medical Association (AMA)
- DOI
- 10.1001/jama.2024.0572
- PMID
- 38324414
- PMCID
- PMC10851143
- eISSN
- 1538-3598
- Language
- English
- Electronic publication date
- 02/07/2024
- Date published
- 03/05/2024
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984557959502771
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