TY - JOUR
T1 - Critical Care Decisions After Large Core Cerebral Infarctions
T2 - A Secondary Analysis From the SELECT2 Trial
AU - for the SELECT2 Investigators
AU - Kasner, Scott E.
AU - Mullen, Michael T.
AU - DeGeorgia, Michael
AU - Blackburn, Spiros
AU - George, Donna K.
AU - Kumar, Monisha
AU - Messe, Steven
AU - Abraham, Michael G.
AU - Chen, Michael
AU - Ortega-Gutierrez, Santiago
AU - Sitton, Clark W.
AU - Burkhardt, Jan Karl
AU - Hussain, Muhammad Shazam
AU - Churilov, Leonid
AU - Sundararajan, Sophia
AU - Hu, Yin C.
AU - Herial, Nabeel A.
AU - Jabbour, Pascal
AU - Gibson, Daniel
AU - Arenillas, Juan F.
AU - Tsai, Jenny P.
AU - Budzik, Ronald F.
AU - Hicks, William J.
AU - Kozak, Osman
AU - Yan, Bernard
AU - Cordato, Dennis J.
AU - Manning, Nathan W.
AU - Parsons, Mark W.
AU - Hanel, Ricardo A.
AU - Aghaebrahim, Amin N.
AU - Wu, Teddy Y.
AU - Portela, Pere Cardona
AU - de la Ossa, Natalia Pérez
AU - Schaafsma, Joanna D.
AU - Blasco, Jordi
AU - Sangha, Navdeep
AU - Warach, Steven
AU - Gandhi, Chirag D.
AU - Kleinig, Timothy J.
AU - Sahlein, Daniel
AU - Samaniego, Edgar A.
AU - Maali, Laith
AU - Abdulrazzak, Mohammad A.
AU - Amuluru, Krishna
AU - Pujara, Deep K.
AU - Shaker, Faris
AU - Johns, Hannah
AU - Moussa, Rami
AU - Al-Shaibi, Faisal
AU - Hill, Michael D.
N1 - Publisher Copyright:
© 2024 American Neurological Association.
PY - 2025/4
Y1 - 2025/4
N2 - Objective: Among patients with large vessel occlusion (LVO) and large ischemic cores, critical decisions often need to be made about decompressive hemicraniectomy (DHC) or early withdrawal of life-sustaining therapy (WLST). In this study, we aimed to evaluate utilization of DHC and early WLST and factors associated with them in patients with large strokes from the SELECT2 trial. Methods: We analyzed the entire SELECT2 trial population, which randomized 352 patients with stroke due to LVO and large ischemic cores to endovascular thrombectomy (EVT) or medical management. We used the as-treated principle to compare the use of DHC and early WLST within 7 days after randomization. We further assessed functional outcomes (modified Rankin Score) after these decisions. Results: Of 352 patients enrolled in this study, 55 received DHC and 81 transitioned to early WLST. Patients treated with EVT were as likely to undergo DHC (16% vs 15%, adjusted relative risk [aRR] = 1.19, 95% CI:0.75–1.88, p = 0.46) or WLST (22% vs 24%, aRR = 0.94, 95% CI: 0.66–1.34, p = 0.72) as those given medical management. DHC was used more frequently in younger patients and WLST more in older patients. EVT efficacy was maintained after adjusting for DHC (adjusted generalized odds ratio [aGenOR] = 1.68, 95% CI: 1.24–2.11, p < 0.001), with no interaction between DHC and treatment (p-interaction = 0.93). At 1 year, 21% of DHC-treated patients were ambulatory; the outcomes were universally poor after early WLST. Interpretation: In the SELECT2 trial of patients with large ischemic core, DHC was performed in ~1 of 6 patients and early WLST in ~1 of 5 patients, without differences based on treatment with EVT or medical management, nor successful reperfusion. DHC or WLST did not detract from thrombectomy treatment benefit. Additionally, ~20% of patients achieved independent ambulation despite receiving DHC by the 1-year follow-up. The similar distribution of these critical care decisions provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation. ANN NEUROL 2025;97:698–708.
AB - Objective: Among patients with large vessel occlusion (LVO) and large ischemic cores, critical decisions often need to be made about decompressive hemicraniectomy (DHC) or early withdrawal of life-sustaining therapy (WLST). In this study, we aimed to evaluate utilization of DHC and early WLST and factors associated with them in patients with large strokes from the SELECT2 trial. Methods: We analyzed the entire SELECT2 trial population, which randomized 352 patients with stroke due to LVO and large ischemic cores to endovascular thrombectomy (EVT) or medical management. We used the as-treated principle to compare the use of DHC and early WLST within 7 days after randomization. We further assessed functional outcomes (modified Rankin Score) after these decisions. Results: Of 352 patients enrolled in this study, 55 received DHC and 81 transitioned to early WLST. Patients treated with EVT were as likely to undergo DHC (16% vs 15%, adjusted relative risk [aRR] = 1.19, 95% CI:0.75–1.88, p = 0.46) or WLST (22% vs 24%, aRR = 0.94, 95% CI: 0.66–1.34, p = 0.72) as those given medical management. DHC was used more frequently in younger patients and WLST more in older patients. EVT efficacy was maintained after adjusting for DHC (adjusted generalized odds ratio [aGenOR] = 1.68, 95% CI: 1.24–2.11, p < 0.001), with no interaction between DHC and treatment (p-interaction = 0.93). At 1 year, 21% of DHC-treated patients were ambulatory; the outcomes were universally poor after early WLST. Interpretation: In the SELECT2 trial of patients with large ischemic core, DHC was performed in ~1 of 6 patients and early WLST in ~1 of 5 patients, without differences based on treatment with EVT or medical management, nor successful reperfusion. DHC or WLST did not detract from thrombectomy treatment benefit. Additionally, ~20% of patients achieved independent ambulation despite receiving DHC by the 1-year follow-up. The similar distribution of these critical care decisions provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation. ANN NEUROL 2025;97:698–708.
UR - https://www.scopus.com/pages/publications/85211622910
U2 - 10.1002/ana.27151
DO - 10.1002/ana.27151
M3 - Artículo
C2 - 39648975
AN - SCOPUS:85211622910
SN - 0364-5134
VL - 97
SP - 698
EP - 708
JO - Annals of Neurology
JF - Annals of Neurology
IS - 4
ER -