TY - JOUR
T1 - Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles
AU - Sarraj, Amrou
AU - Hassan, Ameer E.
AU - Abraham, Michael G.
AU - Ortega-Gutierrez, Santiago
AU - Kasner, Scott E.
AU - Hussain, Muhammad Shazam
AU - Chen, Michael
AU - Churilov, Leonid
AU - Johns, Hannah
AU - Sitton, Clark W.
AU - Yogendrakumar, Vignan
AU - Ng, Felix C.
AU - Pujara, Deep K.
AU - Blackburn, Spiros
AU - Sundararajan, Sophia
AU - Hu, Yin C.
AU - Herial, Nabeel A.
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 - Cheung, Andrew
AU - Hanel, Ricardo A.
AU - Aghaebrahim, Amin N.
AU - Wu, Teddy Y.
AU - Portela, Pere Cardona
AU - Gandhi, Chirag D.
AU - Al-Mufti, Fawaz
AU - de la Ossa, Natalia Pérez
AU - Schaafsma, Joanna D.
AU - Blasco, Jordi
AU - Sangha, Navdeep
AU - Warach, Steven
AU - Kleinig, Timothy J.
AU - Shaker, Faris
AU - Shaibi, Faisal Al
AU - Toth, Gabor
AU - Abdulrazzak, Mohammad A.
AU - Sharma, Gagan
AU - Ray, Abhishek
AU - Sunshine, Jeffrey
AU - Opaskar, Amanda
AU - Duncan, Kelsey R.
AU - Xiong, Wei
AU - Samaniego, Edgar A.
AU - Maali, Laith
AU - Lechtenberg, Colleen G.
AU - Renú, Arturo
AU - Vora, Nirav
AU - Nguyen, Thanh
AU - Fifi, Johanna T.
AU - Tjoumakaris, Stavropoula I.
AU - Jabbour, Pascal
AU - Tsivgoulis, Georgios
AU - Pereira, Vitor Mendes
AU - Lansberg, Maarten G.
AU - DeGeorgia, Michael
AU - Sila, Cathy A.
AU - Bambakidis, Nicholas
AU - Hill, Michael D.
AU - Davis, Stephen M.
AU - Wechsler, Lawrence
AU - Grotta, James C.
AU - Ribo, Marc
AU - Albers, Greg W.
AU - Campbell, Bruce C.
N1 - Publisher Copyright:
© 2024 American Medical Association. All rights reserved.
PY - 2024/3/5
Y1 - 2024/3/5
N2 - IMPORTANCE Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. OBJECTIVE To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. DESIGN, SETTING, AND PARTICIPANTS 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. INTERVENTION EVT vs MM. MAIN OUTCOMES AND MEASURES 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. RESULTS 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. CONCLUSION AND RELEVANCE 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.
AB - IMPORTANCE Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. OBJECTIVE To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. DESIGN, SETTING, AND PARTICIPANTS 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. INTERVENTION EVT vs MM. MAIN OUTCOMES AND MEASURES 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. RESULTS 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. CONCLUSION AND RELEVANCE 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.
UR - https://www.scopus.com/pages/publications/85184815255
U2 - 10.1001/jama.2024.0572
DO - 10.1001/jama.2024.0572
M3 - Artículo
C2 - 38324414
AN - SCOPUS:85184815255
SN - 0098-7484
VL - 331
SP - 750
EP - 763
JO - JAMA
JF - JAMA
IS - 9
ER -