Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes
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Published:2024-04-01
Issue:4
Volume:81
Page:327
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ISSN:2168-6149
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Container-title:JAMA Neurology
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language:en
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Short-container-title:JAMA Neurol
Author:
Sarraj Amrou1, Hill Michael D.2, Hussain M. Shazam3, Abraham Michael G.4, Ortega-Gutierrez Santiago5, Chen Michael6, Kasner Scott E.7, Churilov Leonid8, Pujara Deep K.1, Johns Hannah8, Blackburn Spiros9, Sundararajan Sophia1, Hu Yin C.10, Herial Nabeel A.11, Budzik Ronald F.12, Hicks William J.13, Arenillas Juan F.14, Tsai Jenny P.15, Kozak Osman16, Cordato Dennis J.17, Hanel Ricardo A.18, Wu Teddy Y.19, Portela Pere Cardona20, Gandhi Chirag D.21, Al-Mufti Fawaz21, Maali Laith4, Gibson Daniel22, Pérez de la Ossa Natalia23, Schaafsma Joanna D.24, Blasco Jordi25, Sangha Navdeep26, Warach Steven27, Kleinig Timothy J.28, Shaker Faris9, Sitton Clark W.29, Nguyen Thanh30, Fifi Johanna T.31, Jabbour Pascal11, Furlan Anthony1, Lansberg Maarten G.32, Tsivgoulis Georgios33, Sila Cathy1, Bambakidis Nicholas10, Davis Stephen34, Wechsler Lawrence35, Albers Greg W.32, Grotta James C.36, Ribo Marc37, Campbell Bruce C.38, Hassan Ameer E.39, , , Sarraj Amrou40, Sundararajan Sophia40, Hu Yin40, Sila Cathy40, Furlan Anthony40, Opaskar Amanda40, Bambakidis Nicholas40, Ray Abhishek40, Sunshine Jeffrey40, DeGeorgia Michael40, Xiong Wei40, Duncan Rose40, Fadhil Ali40, Hansen John40, Patel Mohit40, Chugh Arunit40, Al-Shaibi Faisal40, Alomar Majed40, El-Azzouni Soheil40, Moussa Rami B40, Jin Dasul40, Nayak Katrina M40, Zhang Yiyi40, Modak Nikhil S40, Jumah Muruj M40, Liou Deng-Yuan Dean40, Alamoudi Abdullah40, Pujara Deep40, Blackburn Spiros40, Grotta James C.40, Sitton Clark40, Rahbar Mohammad H40, Dannenbaum Mark40, Riascos Roy40, Spiegel Gary40, Barreto Andrew40, Sharieff Anjail40, Cochran Joseph40, Day Arthur L.40, Gonzales Nicole40, Reddy Sujan40, Fournier Lauren40, Jones Erica M40, Zelini Pamela40, Kamal Haris40, Castanon Felix Guerra40, Asim Naveed40, Shaker Faris40, Hessabi Manouchehr40, Tahanan Amirali40, Abraham Michael40, Maali Laith40, Ebersole Koji40, Kawano Jorge40, Lechtenberg Colleen40, Slavin Sabreena40, Maali Latih40, Madarang Ernest40, Pendurthi Aparna40, Qureshi Abid40, Reeves Alan40, Rosterman Lee40, Wang Yunxia40, Barkley Tiffany Thu40, Vanguru Husitha40, Paterson Jeremy40, Walters Carissa40, Ackerman Peyton40, Hanel Ricardo40, Aghaebrahim Amin N40, Sauvageau Eric40, Munden Gina40, Hussain M. Shazam40, Abdulrazzak Mohammad A40, Uchino Ken40, Katzan Irene40, Lu Mei40, Toth Gabor40, Russman Andrew40, Wisco Dolora40, Sundararajan Jayashree40, Buletko Andrew40, Bain Mark40, Moore Nina40, Witek Alex40, Cierny Marek40, Mahapatra Ashutosh40, Kharal Ghulum40, Limbert Denice40, Resser Tina40, Sweeney Laura J40, Chen Michael40, Munich Stephan40, Crowley Richard40, McLaughlin Elizabeth40, Song Sarah40, McWilliams Rebecca40, Jacher Bartosz40, Warach Steven40, Milling Truman J.40, Miley Jefferson40, Ellington Kent40, Regan Aliaksandra40, Erfan Jessica40, Mawla Manzure40, Davis Lisa40, Zuck Nathan40, Budzik Ron F40, Hicks William J40, Vora Nirav40, Pema Peter40, Alhajeri Abdulnasser40, Loochtan Aaron40, Rai Vivek40, Katz Brian40, Koss Adam40, Dedhia Nikita40, Groezinger Katy40, Heckathorn Megan40, Bartelt Heather40, Sangha Navdeep40, Le Duy40, Feng Lei 40, Chao Kuo40, Cheng Pamela K40, Ajani Zahra A40, Lui Catherine L40, Sharma Ashima40, Kozak Osman40, Mackenzie Larami40, Choe Hana40, Bussinger Patricia40, DePalmo Ashley40, Hassan Ameer E40, Tekle Wondwossen40, Georgiadis Alexandros40, Sanchez Olive40, Smith Pualani40, Gibson Daniel40, Wallace Adam40, Mente Tracy40, Wilson Margaret40, Ortega-Gutierrez Santiago40, Samaniego Edgar40, Derdeyn Colin40, Dlouhy Kathleen40, Hasan David40, Hayakawa Minako40, Leira Enrique40, Limaye Kaustubh40, Shaban Amir40, Shim Hyung Sub40, Ghannam Malik40, Zeballos Cynthia40, Maljaars Jason40, Koul Prateeka40, Almajali Mohammad40, Olalde Heena40, Kekinagath Harika A40, Elijovich Lucas40, Arthur Adam40, Hoit Daniel40, Nickele Christopher40, Inoa Violiza40, Goyal Nitin40, Wilson Stephanie40, Parsha Kaushik40, Nolte Amanda40, Herial Nabeel40, Jabbour Pascal40, Tjoumakaris Stavropoula40, Gooch Michael Reid40, Theofanis Thana40, Rosenwasser Robert H.40, Schunemann Victoria40, Tahir Rizwan40, Eldin Mohamed S40, Jabre Roland40, Chen Jared40, Jones Nadirah40, Kasner Scott40, Cucchiara Brett L40, Messe Steven Russell40, Witsch Jens40, George Donna40, Favilla Christopher40, Yuan Qingyang40, Stein Laura A40, Novello Paul40, Rothstein Aaron40, Cristancho Daniel40, Sloane Kelly40, Humbert Kelley40, Zuflacht Jonah40, Kumar Arooshi40, Khan Farhan40, Mullen Michael40, Dawod Judy40, Burkhardt Jan-Karl40, Jankowitz Brian40, Pukenas Bryan40, Choudhri Omar40, Ramchand Preethi40, Reyes-Esteves Sahily40, Kone Gbambele40, Kvantaliani Nino40, Rosso Michela40, Cole Sydni40, Khazaal Ossama40, Gallatti Nichole40, Tsai Jenny40, Min Jiangyong40, Wees Nabil40, Abdallah Amjad40, Khan Muhib A.40, Khan Nadeem40, Ahrar Asad40, Mazaris Paul40, Malgorzata Miller40, Singer Justin40, Groseclose Ryan S.40, Sultan Beenish I.40, Sahlein Daniel40, Amuluru Krishna40, Scott John40, DeNardo Andrew40, Rosenbaum David40, Campbell Kati40, Gandhi Chirag40, Al-Mufti Fawaz40, Kaur Gurmeen40, Santarelli Justin40, Lemrick Nicole40, Cero Heather40, Clare Kevin40, Nolan Bridget40, Schaafsma Joanna40, Stewart Tim40, Cayley Anne40, Jaigobin Cheryl40, Casaubon Leanne40, Nicholson Patrick40, Agid Ronit40, Silver Frank40, Pikula Aleksandra40, To William40, Crellin Lisa40, Shuaib Ashfaq40, Sobreira Nina40, Campbell Bruce C40, Yan Bernard40, Yogendrakumar Vignan40, Ng Felix C40, Mitchell Peter J40, Dowling Richard J40, Bush Steven J40, Williams Cameron40, Yassi Nawaf40, Pavlin-Premrl Davor40, Beharry James40, Balabanski Anna40, Santos Angela Dos40, Sharobeam Angelos40, Valente Michael40, Park Ashley40, Wong Joseph40, McDonald Amy40, Jackson David40, Sharma Gagan40, Guha Prodipta40, Rokaha Birendra40, Kleinig Timothy J40, Scroop Rebecca40, Kurunawai Craig40, Mahadevan Joshua40, Goh Rudy40, Drew Roy40, Cordato Dennis40, Manning Nathan40, Parsons Mark40, McQuinn Alex40, Wenderoth Jason40, Cheung Andrew40, McDougall Alan40, Thomas James40, Cappelen-Smith Cecilia40, Blair Christopher40, Edwards Leon40, Whitely Justin40, Helou Jacob40, Miller Megan40, Wu Teddy Y40, Collecutt Wayne40, Colgan Frances40, Krauss Martin40, Laing Andrew40, Wilson Duncan40, Fink John40, LeHeron Campbell40, Mason Deborah40, Green Rosemary40, Bremner Kathleen40, Ribo Marc40, Tomasello Alejandro40, Requena Ruiz Manuel40, Olive Gadea Marta40, Sanjuan Estela40, Cendrero Judith40, Blasco Jordi40, Renu Arturo40, San Roman Luis40, Urra Xabier40, Santana Daniel40, Maria Cabrera Jose40, Llull Laura40, López-Rueda Antonio40, Cabero Andrea40, Serrano Elena40, Perez de la Ossa Natalia40, Hernández-Pérez Maria40, Millán Mònica40, Gomis Meritxell40, Bustamante Alejandro40, Dorado Laura40, Gómez-Choco Manuel40, Remollo Sebastià40, Castaño Carlos40, Werner Mariano40, Muñoz-Narbona Lucia40, Cardona Pere40, Quesada Helena40, Lara Blanca40, Paipa Andres40, Nuñez Anna40, Cuba Victor40, Chirife Oscar40, Aja Lucia40, de Miquel Maria Angeles40, Arenillas Juan F40, De Lera Alfonso Mercedes40, Araque María Esther Ramos40, Calleja Ana I40, Cortijo Elisa40, Martínez-Galdámez Mario40, Schüller Miguel40, Galván Jorge40, Reyes Muñoz Javier40, Vicente Gómez Beatriz40, Psychogios Marios40, Brehm Alex40, Vora Nirav12, Manning Nathan W.41, Cheung Andrew41, Aghaebrahim Amin N.18, Paipa Merchán Andres J.42, Sahlein Daniel43, Requena Ruiz Manuel44, Elijovich Lucas45, Arthur Adam45, Al-Shaibi Faisal1, Samaniego Edgar A.46, Duncan Kelsey R.1, Opaskar Amanda1, Ray Abhishek10, Xiong Wei1, Sunshine Jeffery10, DeGeorgia Michael1, Tjoumakaris Stavropoula11, Mendes Pereira Vitor47
Affiliation:
1. Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio 2. Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada 3. Cerebrovascular Center, Neurology, Cleveland Clinic, Cleveland, Ohio 4. Neurology, University of Kansas Medical Center, Kansas City 5. Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City 6. Neurosurgery, Rush University Medical Center, Chicago, Illinois 7. Neurology, University of Pennsylvania, Philadelphia 8. Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia 9. Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas 10. Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio 11. Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 12. Neuro-Interventional Radiology, OhioHealth, Riverside Methodist Hospital, Columbus 13. Neurology, OhioHealth, Riverside Methodist Hospital, Columbus 14. Internal Medicine, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain 15. Neurosurgery, Cleveland Clinic, Cleveland, Ohio 16. Neurosurgery, Abington Jefferson Health, Abington, Pennsylvania 17. Neurology, Liverpool Hospital, Liverpool, Australia 18. Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida 19. Neurology, Christchurch Hospital, Christchurch, New Zealand 20. Neurology, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain 21. Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York 22. Neurointerventional Surgery, Ascension Columbia St Mary’s Hospital, Milwaukee, Wisconsin 23. Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain 24. Internal Medicine, Toronto Western Hospital, Toronto, Ontario, Canada 25. Stroke Unit, Hospital Clínic de Barcelona, Barcelona, Spain 26. Neurology, Kaiser Permanente Southern California, Los Angeles 27. Neurology, Dell Medical School at The University of Texas at Austin, Ascension Texas, Austin 28. Neurology, Royal Adelaide Hospital, Adelaide, Australia 29. Interventioal and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, Texas 30. Neurology, Boston Medical Center, Boston, Massachusetts 31. Neurology, Icahn School of Medicine at Mount Sinai, New York, New York 32. Neurology, Stanford University, Stanford, California 33. Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece 34. Neurology, The Royal Melbourne Hospital, Melbourne, Australia 35. Neurology, Hospitals of University of Pennsylvania, Philadelphia 36. Mobile Stroke Unit, Memorial Hermann Hospital, Houston, Texas 37. Neurology, Hospital Vall d’Hebrón, Sabadell, Spain 38. Medicine and Neurology, The Royal Melbourne Hospital, The Florey Institute for Neuroscience and Mental Health, Melbourne, Australia 39. Neuroscience, Valley Baptist Medical Center, Harlingen, Texas 40. and the SELECT2 Collaborators 41. Neurosurgery, Liverpool Hospital, Liverpool, Australia 42. Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Spain 43. Interventional Neuroradiology, Goodman Campbell Brain and Spine, Indianapolis, Indiana 44. Hospital Vall d’Hebrón, Barcelona, Spain 45. Semmes Murphey Clinic, Memphis, Tennessee 46. Neurology, University of Iowa Hospitals and Clinics, Iowa City 47. Neurology, St Michael’s Hospital, Toronto, Ontario, Canada
Abstract
ImportancePatients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT).ObjectiveTo assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes.Design, Setting, and ParticipantsThis prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024.InterventionsEVT vs MM.Main Outcomes and MeasuresFunctional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication.ResultsA total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80).Conclusions and RelevanceBoth directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport.Trial RegistrationClinicalTrials.gov Identifier: NCT03876457
Publisher
American Medical Association (AMA)
Cited by
2 articles.
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