Amrou Sarraj1, Ameer E Hassan2,3,4, Sean Savitz1, Clark Sitton5, James Grotta1, Peng Chen6, Chunyan Cai7, Gary Cutter8, Bita Imam1, Sujan Reddy1, Kaushik Parsha1, Deep Pujara1, Roy Riascos5, Nirav Vora9, Michael Abraham10, Haris Kamal1, Diogo C Haussen11, Andrew D Barreto1, Maarten Lansberg12, Rishi Gupta13, Gregory W Albers12. 1. Department of Neurology, University of Texas McGovern Medical School, Houston. 2. Department of Neurology, University of Texas Rio Grande Valley, Harlingen. 3. Department of Neurology, University of Texas Health Science Center, Neurology, San Antonio. 4. Department of Radiology, University of Texas Health Science Center, San Antonio. 5. Department of Radiology, University of Texas McGovern Medical School, Houston. 6. Department of Neurosurgery, University of Texas McGovern Medical School, Houston. 7. Clinical and Translational Science, University of Texas McGovern Medical School, Houston. 8. Department of Biostatistics, University of Alabama at Birmingham. 9. Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus. 10. Department of Neurology, University of Kansas Medical Center, Kansas City. 11. Department of Neurology, Emory University, Atlanta, Georgia. 12. Department of Neurology, Stanford University, Stanford, California. 13. Department of Neurology, Wellstar Health System, Atlanta, Georgia.
Abstract
IMPORTANCE: The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge. OBJECTIVE: To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone. DESIGN, SETTING, AND PARTICIPANTS: This prespecified analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score <6) or CT perfusion scanning (a volume with a relative cerebral blood flow <30% of ≥50 cm3) were included in analyses. EXPOSURES: Endovascular thrombectomy with medical management (MM) or MM only. MAIN OUTCOMES AND MEASURES: Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening). RESULTS: A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome. CONCLUSIONS AND RELEVANCE: Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed.
IMPORTANCE: The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge. OBJECTIVE: To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone. DESIGN, SETTING, AND PARTICIPANTS: This prespecified analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score <6) or CT perfusion scanning (a volume with a relative cerebral blood flow <30% of ≥50 cm3) were included in analyses. EXPOSURES: Endovascular thrombectomy with medical management (MM) or MM only. MAIN OUTCOMES AND MEASURES: Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening). RESULTS: A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome. CONCLUSIONS AND RELEVANCE: Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed.
Authors: E A Mistry; A M Mistry; T Mehta; N Arora; A K Starosciak; F D L R La Rosa; J E Siegler; S E Kasner; R Chitale; M Fusco; M Froehler; S Yaghi; M Schrag; P Khatri Journal: AJNR Am J Neuroradiol Date: 2020-03-12 Impact factor: 3.825
Authors: James E Siegler; Andrew Olsen; Jon Rosenberg; Daniel Cristancho; Johannes Pulst-Korenberg; Lindsay Raab; John H Woo; Steven R Messé Journal: Clin Neurol Neurosurg Date: 2020-03-19 Impact factor: 1.876
Authors: Bruce C V Campbell; Maarten G Lansberg; Gregory W Albers; Joseph P Broderick; Colin P Derdeyn; Pooja Khatri; Amrou Sarraj; Jeffrey L Saver; Achala Vagal Journal: Stroke Date: 2021-07-08 Impact factor: 10.170