Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles
Author:
Sarraj Amrou1, Hassan Ameer E.2, Abraham Michael G.3, Ortega-Gutierrez Santiago4, Kasner Scott E.5, Hussain Muhammad Shazam6, Chen Michael7, Churilov Leonid8, Johns Hannah8, Sitton Clark W.9, Yogendrakumar Vignan8, Ng Felix C.8, Pujara Deep K.1, Blackburn Spiros9, Sundararajan Sophia1, Hu Yin C.1, Herial Nabeel A.10, Arenillas Juan F.11, Tsai Jenny P.12, Budzik Ronald F.13, Hicks William J.13, Kozak Osman14, Yan Bernard8, Cordato Dennis J.15, Manning Nathan W.15, Parsons Mark W.15, Cheung Andrew15, Hanel Ricardo A.16, Aghaebrahim Amin N.16, Wu Teddy Y.17, Portela Pere Cardona18, Gandhi Chirag D.19, Al-Mufti Fawaz19, Pérez de la Ossa Natalia20, Schaafsma Joanna D.21, Blasco Jordi22, Sangha Navdeep23, Warach Steven24, Kleinig Timothy J.25, Shaker Faris9, Al Shaibi Faisal1, Toth Gabor6, Abdulrazzak Mohammad A.6, Sharma Gagan8, Ray Abhishek1, Sunshine Jeffrey1, Opaskar Amanda1, Duncan Kelsey R.1, Xiong Wei1, Samaniego Edgar A.4, Maali Laith3, Lechtenberg Colleen G.3, Renú Arturo22, Vora Nirav13, Nguyen Thanh26, Fifi Johanna T.27, Tjoumakaris Stavropoula I.10, Jabbour Pascal10, Tsivgoulis Georgios28, Pereira Vitor Mendes29, Lansberg Maarten G.30, DeGeorgia Michael1, Sila Cathy A.1, Bambakidis Nicholas1, Hill Michael D.31, Davis Stephen M.8, Wechsler Lawrence32, Grotta James C.33, Ribo Marc34, Albers Greg W.30, Campbell Bruce C.835, , Sarraj Amrou36, Sundararajan Sophia36, Hu Yin36, Sila Cathy36, Furlan Anthony36, Opaskar Amanda36, Bambakidis Nicholas36, Ray Abhishek36, Sunshine Jeffrey36, DeGeorgia Michael36, Xiong Wei36, Duncan Rose36, Fadhil Ali36, Hansen John36, Patel Mohit36, Chugh Arunit36, Al-Shaibi Faisal36, Alomar Majed36, El-Azzouni Soheil36, Moussa Rami B36, Jin Dasul36, Nayak Katrina M36, Zhang Yiyi36, Modak Nikhil S36, Jumah Muruj M36, Liou Deng-Yuan Dean36, Alamoudi Abdullah36, Pujara Deep36, Blackburn Spiros36, Grotta James C.36, Sitton Clark36, Rahbar Mohammad H36, Dannenbaum Mark36, Riascos Roy36, Spiegel Gary36, Barreto Andrew36, Sharieff Anjail36, Cochran Joseph36, Day Arthur L.36, Gonzales Nicole36, Reddy Sujan36, Fournier Lauren36, Jones Erica M36, Zelini Pamela36, Kamal Haris36, Castanon Felix Guerra36, Asim Naveed36, Shaker Faris36, Hessabi Manouchehr36, Tahanan Amirali36, Abraham Michael36, Maali Laith36, Ebersole Koji36, Kawano Jorge36, Lechtenberg Colleen36, Slavin Sabreena36, Maali Latih36, Madarang Ernest36, Pendurthi Aparna36, Qureshi Abid36, Reeves Alan36, Rosterman Lee36, Wang Yunxia36, Barkley Tiffany Thu36, Vanguru Husitha36, Paterson Jeremy36, Walters Carissa36, Ackerman Peyton36, Hanel Ricardo36, Aghaebrahim Amin N36, Sauvageau Eric36, Munden Gina36, Hussain M. Shazam36, Abdulrazzak Mohammad A36, Uchino Ken36, Katzan Irene36, Lu Mei36, Toth Gabor36, Russman Andrew36, Wisco Dolora36, Sundararajan Jayashree36, Buletko Andrew36, Bain Mark36, Moore Nina36, Witek Alex36, Cierny Marek36, Mahapatra Ashutosh36, Kharal Ghulum36, Limbert Denice36, Resser Tina36, Sweeney Laura J36, Chen Michael36, Munich Stephan36, Crowley Richard36, McLaughlin Elizabeth36, Song Sarah36, McWilliams Rebecca36, Jacher Bartosz36, Warach Steven36, Milling Truman J.36, Miley Jefferson36, Ellington Kent36, Regan Aliaksandra36, Erfan Jessica36, Mawla Manzure36, Davis Lisa36, Zuck Nathan36, Budzik Ron F36, Hicks William J36, Vora Nirav36, Pema Peter36, Alhajeri Abdulnasser36, Loochtan Aaron36, Rai Vivek36, Katz Brian36, Koss Adam36, Dedhia Nikita36, Groezinger Katy36, Heckathorn Megan36, Bartelt Heather36, Sangha Navdeep36, Le Duy36, Feng Lei 36, Chao Kuo36, Cheng Pamela K36, Ajani Zahra A36, Lui Catherine L36, Sharma Ashima36, Kozak Osman36, Mackenzie Larami36, Choe Hana36, Bussinger Patricia36, DePalmo Ashley36, Hassan Ameer E36, Tekle Wondwossen36, Georgiadis Alexandros36, Sanchez Olive36, Smith Pualani36, Gibson Daniel36, Wallace Adam36, Mente Tracy36, Wilson Margaret36, Ortega-Gutierrez Santiago36, Samaniego Edgar36, Derdeyn Colin36, Dlouhy Kathleen36, Hasan David36, Hayakawa Minako36, Leira Enrique36, Limaye Kaustubh36, Shaban Amir36, Shim Hyung Sub36, Ghannam Malik36, Zeballos Cynthia36, Maljaars Jason36, Koul Prateeka36, Almajali Mohammad36, Olalde Heena36, Kekinagath Harika A36, Elijovich Lucas36, Arthur Adam36, Hoit Daniel36, Nickele Christopher36, Inoa Violiza36, Goyal Nitin36, Wilson Stephanie36, Parsha Kaushik36, Nolte Amanda36, Herial Nabeel36, Jabbour Pascal36, Tjoumakaris Stavropoula36, Gooch Michael Reid36, Theofanis Thana36, Rosenwasser Robert H.36, Schunemann Victoria36, Tahir Rizwan36, Eldin Mohamed S36, Jabre Roland36, Chen Jared36, Jones Nadirah36, Kasner Scott36, Cucchiara Brett L36, Messe Steven Russell36, Witsch Jens36, George Donna36, Favilla Christopher36, Yuan Qingyang36, Stein Laura A36, Novello Paul36, Rothstein Aaron36, Cristancho Daniel36, Sloane Kelly36, Humbert Kelley36, Zuflacht Jonah36, Kumar Arooshi36, Khan Farhan36, Mullen Michael36, Dawod Judy36, Burkhardt Jan-Karl36, Jankowitz Brian36, Pukenas Bryan36, Choudhri Omar36, Ramchand Preethi36, Reyes-Esteves Sahily36, Kone Gbambele36, Kvantaliani Nino36, Rosso Michela36, Cole Sydni36, Khazaal Ossama36, Gallatti Nichole36, Tsai Jenny36, Min Jiangyong36, Wees Nabil36, Abdallah Amjad36, Khan Muhib A.36, Khan Nadeem36, Ahrar Asad36, Mazaris Paul36, Malgorzata Miller36, Singer Justin36, Groseclose Ryan S.36, Sultan Beenish I.36, Sahlein Daniel36, Amuluru Krishna36, Scott John36, DeNardo Andrew36, Rosenbaum David36, Campbell Kati36, Gandhi Chirag36, Al-Mufti Fawaz36, Kaur Gurmeen36, Santarelli Justin36, Lemrick Nicole36, Cero Heather36, Clare Kevin36, Nolan Bridget36, Schaafsma Joanna36, Stewart Tim36, Cayley Anne36, Jaigobin Cheryl36, Casaubon Leanne36, Nicholson Patrick36, Agid Ronit36, Silver Frank36, Pikula Aleksandra36, To William36, Crellin Lisa36, Shuaib Ashfaq36, Sobreira Nina36, Campbell Bruce C36, Yan Bernard36, Yogendrakumar Vignan36, Ng Felix C36, Mitchell Peter J36, Dowling Richard J36, Bush Steven J36, Williams Cameron36, Yassi Nawaf36, Pavlin-Premrl Davor36, Beharry James36, Balabanski Anna36, Santos Angela Dos36, Sharobeam Angelos36, Valente Michael36, Park Ashley36, Wong Joseph36, McDonald Amy36, Jackson David36, Sharma Gagan36, Guha Prodipta36, Rokaha Birendra36, Kleinig Timothy J36, Scroop Rebecca36, Kurunawai Craig36, Mahadevan Joshua36, Goh Rudy36, Drew Roy36, Cordato Dennis36, Manning Nathan36, Parsons Mark36, McQuinn Alex36, Wenderoth Jason36, Cheung Andrew36, McDougall Alan36, Thomas James36, Cappelen-Smith Cecilia36, Blair Christopher36, Edwards Leon36, Whitely Justin36, Helou Jacob36, Miller Megan36, Wu Teddy Y36, Collecutt Wayne36, Colgan Frances36, Krauss Martin36, Laing Andrew36, Wilson Duncan36, Fink John36, LeHeron Campbell36, Mason Deborah36, Green Rosemary36, Bremner Kathleen36, Ribo Marc36, Tomasello Alejandro36, Ruiz Manuel Requena36, Gadea Marta Olive36, Sanjuan Estela36, Cendrero Judith36, Blasco Jordi36, Renu Arturo36, Roman Luis San36, Urra Xabier36, Santana Daniel36, Cabrera Jose Maria36, Llull Laura36, López-Rueda Antonio36, Cabero Andrea36, Serrano Elena36, Ossa Natalia Perez de la36, Hernández-Pérez Maria36, Millán Mònica36, Gomis Meritxell36, Bustamante Alejandro36, Dorado Laura36, Gómez-Choco Manuel36, Remollo Sebastià36, Castaño Carlos36, Werner Mariano36, Muñoz-Narbona Lucia36, Cardona Pere36, Quesada Helena36, Lara Blanca36, Paipa Andres36, Nuñez Anna36, Cuba Victor36, Chirife Oscar36, Aja Lucia36, Miquel Maria Angeles de36, Arenillas Juan F36, Alfonso Mercedes De Lera36, Araque María Esther Ramos36, Calleja Ana I36, Cortijo Elisa36, Martínez-Galdámez Mario36, Schüller Miguel36, Galván Jorge36, Muñoz Javier Reyes36, Vicente Beatriz Gómez36, Psychogios Marios36, Brehm Alex36
Affiliation:
1. University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio 2. Valley Baptist Medical Center, Harlingen, Texas 3. University of Kansas Medical Center, Kansas City 4. University of Iowa Hospitals and Clinics, Iowa City 5. University of Pennsylvania, Philadelphia 6. Cleveland Clinic, Cleveland, Ohio 7. Rush University Medical Center, Chicago, Illinois 8. The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia 9. McGovern Medical School at UTHealth, Houston, Texas 10. Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 11. Hospital Clínico Universitario Valladolid—University of Valladolid, Valladolid, Spain 12. Spectrum Health, Michigan 13. Riverside Methodist Hospital, OhioHealth, Columbus 14. Abington Jefferson Health, Abington, Pennsylvania 15. Liverpool Hospital, Liverpool, New South Wales, Australia 16. Baptist Medical Center Jacksonville, Jacksonville, Florida 17. Christchurch Hospital, Christchurch, New Zealand 18. Hospital Universitari de Bellvitge, Barcelona, Spain 19. Westchester Medical Center, New York Medical College, Valhalla 20. Hospital Universitari Germans Trias i Pujol, Barcelona, Spain 21. Toronto Western Hospital, Toronto, Ontario, Canada 22. Hospital Clínic de Barcelona, Barcelona, Spain 23. Kaiser Permanente Southern California, Los Angeles 24. Dell Medical School at The University of Texas at Austin–Ascension Texas, Austin 25. Royal Adelaide Hospital, Adelaide, South Australia, Australia 26. Boston Medical Center, Boston, Massachusetts 27. Icahn School of Medicine at Mount Sinai, New York, New York 28. Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece 29. St Michael’s Hospital, Toronto, Ontario, Canada 30. Stanford University, Stanford, California 31. University of Calgary, Calgary, Alberta, Canada 32. Hospitals of University of Pennsylvania, Philadelphia 33. Memorial Hermann Hospital, Houston, Texas 34. Hospital Vall d’Hebrón, Barcelona, Spain 35. Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia 36. for the SELECT2 Investigators
Abstract
ImportanceWhether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain.ObjectiveTo 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 ParticipantsAn 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.InterventionEVT vs MM.Main Outcomes and MeasuresPrimary 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.ResultsAmong 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 RelevanceIn 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.Trial RegistrationClinicalTrials.gov Identifier: NCT03876457
Publisher
American Medical Association (AMA)
Cited by
18 articles.
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