Endovascular thrombectomy improves medical care outcomes for large ischemic strokes
Presenter: Amrou Sarraj, MD, University of Texas Health Science Center at Houston, Houston, TX
A randomized trial of endovascular thrombectomy versus medical management for ischemic stroke with a large core infarct on noncontrast CT or perfusion imaging. April 25, 2023.
In patients with large vessel occlusion ischemic stroke, endovascular thrombectomy plus medical care improved functional outcomes, functional independence, and independent walking when compared with medical care only, according to results from the SELECT 2 trial presented by Amrou Sarraj, MD, of The University of Texas Health Science Center at Houston, Houston, TX.
The efficacy and safety of endovascular thrombectomy have been established in patients with minimal ischemic changes (small core); however, patients with large core have been underrepresented in most clinical trials, Sarraj said. Large core infarcts have a large area of infarct with irreversible changes that carries a higher risk of reperfusion injury. These patients may still benefit from intervention, but they have lower rates of functional independence than those with small core infarcts.
Small core infarcts are defined by an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) score of 6 or greater and regional cerebral blood flow of less than 50 mL. Patients with large core infarcts have ASPECTS scores of less than 6 or regional cerebral blood flow volume of more than 50 mL.
The extent of ischemic injury may differ on different imaging modalities. Noncontrast CT identifies hypodense tissue; CT perfusion imaging identifies regions of very low blood flow or volume; and MRI diffusion imaging identifies tissue with cytotoxic edema.
The prospective, randomized, open-label, international SELECT 2 trial was designed to evaluate the safety and efficacy of endovascular thrombectomy plus medical care as compared to medical care only up to 24 hours in patients with acute ischemic stroke with a large vessel occlusion and large core using all 3 imaging modalities. A total of 352 patients were randomized to endovascular thrombectomy (178 patients) or to medical care only (174 patients). Patient baseline characteristics were well-balanced.
The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Key secondary outcomes included functional independence and independent ambulation.
The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51. A total of 20% of the patients in the thrombectomy group and 7% in the medical care group had functional independence. Mortality was similar in the 2 groups.
Symptomatic intracerebral hemorrhage was infrequent and not higher with endovascular thrombectomy. Access site complications occurred in 3% of patients, vascular perforation in 5% and dissection in 6% of patients. Early neurological worsening was increased, potentially related to infarct edema. Despite this, subgroups with unequivocally large core demonstrated benefit, Sarraj said.
“In patients with anterior circulation large vessel occlusion ischemic stroke with low ASPECTS and/or large ischemic core, endovascular thrombectomy improved functional outcomes versus medical care,” he said. “Functional independence and independent ambulation were also improved with thrombectomy.”
References
Sarraj A. A randomized trial of endovascular thrombectomy versus medical management for ischemic stroke with a large core infarct on non-contrast CT or perfusion imaging. Presented at the 75th Annual Meeting of the American Academy of Neurology, April 25, 2023.
Sarraj A, Hassan AE, Abraham MG, et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med 2023; 388(14):1259-1271. doi:10.1056/NEJMoa2214403. Epub 2023 Feb 10.
Huo X, Ma G, Tong X, et al. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med 2023; 388(14):1272-1283. doi:10.1056/NEJMoa2213379. Epub 2023 Feb 10.
Uchida K, Shindo S, Yoshimura S, et al. Association between Alberta Stroke Program Early Computed Tomography score and efficacy and safety outcomes with endovascular therapy in patients with stroke from large-vessel occlusion: A secondary analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT). JAMA Neurol 2022; 79(12):1260-1266. doi:10.1001/jamaneurol.2022.3285.
Disclosures
Amrou Sarraj: Principal investigator and global principal investigator SELECT trial.