Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial

Scott E Kasner; Michael T Mullen; Michael DeGeorgia; Spiros Blackburn; Donna K George; Monisha Kumar; Steven Messe; Michael G Abraham; Michael Chen; Santiago Ortega-Gutierrez; Clark W Sitton; Jan-Karl Burkhardt; Muhammad Shazam Hussain; Leonid Churilov; Sophia Sundararajan; Yin C Hu; Nabeel A Herial; Pascal Jabbour; Daniel Gibson; Juan F Arenillas; Jenny P Tsai; Ronald F Budzik; William J Hicks; Osman Kozak; Bernard Yan; Dennis J Cordato; Nathan W Manning; Mark W Parsons; Ricardo A Hanel; Amin N Aghaebrahim; Teddy Y Wu; Pere Cardona Portela; Natalia Pérez de la Ossa; Joanna D Schaafsma; Jordi Blasco; Navdeep Sangha; Steven Warach; Chirag D Gandhi; Timothy J Kleinig; Daniel Sahlein; Edgar A Samaniego; Laith Maali; Mohammad A Abdulrazzak; Krishna Amuluru; Deep K Pujara; Faris Shaker; Hannah Johns; Rami Moussa; Faisal Al-Shaibi; Kelsey R Duncan; Stavropoula Tjoumakaris; Amanda Opaskar; Wei Xiong; Abhishek Ray; Sepideh Amin-Hanjani; Thanh N Nguyen; Johanna T Fifi; Stephen Davis; Lawrence Wechsler; Anthony Furlan; Cathy Sila; Nicholas Bambakidis; Michael D Hill; Vitor Mendes Pereira; Maarten G Lansberg; James C Grotta; Marc Ribo; Greg W Albers; Bruce C Campbell; Ameer E Hassan; Amrou Sarraj; SELECT2 Investigators

doi:10.1002/ana.27151

Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial

Ann Neurol. 2024 Dec 9. doi: 10.1002/ana.27151. Online ahead of print.

Authors

Scott E Kasner¹, Michael T Mullen², Michael DeGeorgia³, Spiros Blackburn⁴, Donna K George¹, Monisha Kumar¹, Steven Messe¹, Michael G Abraham⁵, Michael Chen⁶, Santiago Ortega-Gutierrez⁷, Clark W Sitton⁸, Jan-Karl Burkhardt¹, Muhammad Shazam Hussain⁹, Leonid Churilov¹⁰, Sophia Sundararajan³, Yin C Hu¹¹, Nabeel A Herial¹², Pascal Jabbour¹², Daniel Gibson¹³, Juan F Arenillas¹⁴, Jenny P Tsai¹⁵, Ronald F Budzik¹⁶, William J Hicks¹⁷, Osman Kozak¹⁸, Bernard Yan¹⁹, Dennis J Cordato²⁰, Nathan W Manning²¹, Mark W Parsons²², Ricardo A Hanel²³, Amin N Aghaebrahim²³, Teddy Y Wu²⁴, Pere Cardona Portela²⁵, Natalia Pérez de la Ossa²⁶, Joanna D Schaafsma²⁷, Jordi Blasco²⁸, Navdeep Sangha²⁹, Steven Warach³⁰, Chirag D Gandhi³¹, Timothy J Kleinig³², Daniel Sahlein³³, Edgar A Samaniego³⁴, Laith Maali⁵, Mohammad A Abdulrazzak³⁵, Krishna Amuluru³³, Deep K Pujara³, Faris Shaker⁴, Hannah Johns¹⁰, Rami Moussa³, Faisal Al-Shaibi³, Kelsey R Duncan³, Stavropoula Tjoumakaris¹², Amanda Opaskar³, Wei Xiong³, Abhishek Ray¹¹, Sepideh Amin-Hanjani¹¹, Thanh N Nguyen³⁶, Johanna T Fifi³⁷, Stephen Davis¹⁹, Lawrence Wechsler³⁸, Anthony Furlan³, Cathy Sila³, Nicholas Bambakidis¹¹, Michael D Hill³⁹, Vitor Mendes Pereira⁴⁰, Maarten G Lansberg⁴¹, James C Grotta⁴², Marc Ribo⁴³, Greg W Albers⁴¹, Bruce C Campbell⁴⁴, Ameer E Hassan⁴⁵, Amrou Sarraj⁴⁶; SELECT2 Investigators

Affiliations

¹ Department of Neurology, University of Pennsylvania, Philadelphia, PA.
² Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
³ Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.
⁴ Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX.
⁵ Department of Neurology, University of Kansas Medical Center, Kansas City, KS.
⁶ Department of Neurosurgery, Rush University Medical Center, Chicago, IL.
⁷ Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Coralville, IA.
⁸ Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX.
⁹ Cerebrovascular Center, Department of Neurology, Cleveland Clinic Neurological Institute, Cleveland, OH.
¹⁰ Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
¹¹ Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.
¹² Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA.
¹³ Department of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI.
¹⁴ Department of Neurology, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain.
¹⁵ Department of Neurosurgery, Spectrum Health, Grand Rapids, MI.
¹⁶ Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH.
¹⁷ Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH.
¹⁸ Department of Neurosurgery, Abington Jefferson Health, Abington, PA.
¹⁹ Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
²⁰ Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia.
²¹ Department of Neurosurgery, Liverpool Hospital, Liverpool, New South Wales, Australia.
²² Department of Neurology, University of New South Wales-Liverpool Hospital, Liverpool, New South Wales, Australia.
²³ Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL.
²⁴ Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.
²⁵ Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain.
²⁶ Department of Neurology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
²⁷ Department of Internal Medicine and Neurology, Toronto Western Hospital, Toronto, Ontario, Canada.
²⁸ Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain.
²⁹ Department of Neurology, Kaiser Permanente Southern California, Pasadena, CA.
³⁰ Department of Neurology, Dell Medical School at The University of Texas at Austin, Austin, TX.
³¹ Department of Neurosurgery, Westchester Medical Center - NY Medical College, New York, NY.
³² Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
³³ Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN.
³⁴ Department of Neurology, University of Iowa Hospitals and Clinics, Coralville, IA.
³⁵ Department of Cerebrovascular Diseases, Cleveland Clinic, Cleveland, OH.
³⁶ Department of Neurology, Boston Medical Center, Boston, MA.
³⁷ Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY.
³⁸ Department of Neurology, Hospitals of University of Pennsylvania, Philadelphia, PA.
³⁹ Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.
⁴⁰ Department of Neurology, St. Michael's Hospital, Toronto, Ontario, Canada.
⁴¹ Department of Neurology, Stanford University, Stanford, CA.
⁴² Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX.
⁴³ Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain.
⁴⁴ Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne and The Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia.
⁴⁵ Department of Neuroscience, Valley Baptist Medical Center, Brownsville, TX.
⁴⁶ Department of Neurology and Stroke, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.

PMID: 39648975
DOI: 10.1002/ana.27151

Abstract

Objective: Among patients with large vessel occlusion (LVO) and large ischemic cores, critical decisions often need to be made about decompressive hemicraniectomy (DHC) or early withdrawal of life-sustaining therapy (WLST). In this study, we aimed to evaluate utilization of DHC and early WLST and factors associated with them in patients with large strokes from the SELECT2 trial.

Methods: We analyzed the entire SELECT2 trial population, which randomized 352 patients with stroke due to LVO and large ischemic cores to endovascular thrombectomy (EVT) or medical management. We used the as-treated principle to compare the use of DHC and early WLST within 7 days after randomization. We further assessed functional outcomes (modified Rankin Score) after these decisions.

Results: Of 352 patients enrolled in this study, 55 received DHC and 81 transitioned to early WLST. Patients treated with EVT were as likely to undergo DHC (16% vs 15%, adjusted relative risk [aRR] = 1.19, 95% CI:0.75-1.88, p = 0.46) or WLST (22% vs 24%, aRR = 0.94, 95% CI: 0.66-1.34, p = 0.72) as those given medical management. DHC was used more frequently in younger patients and WLST more in older patients. EVT efficacy was maintained after adjusting for DHC (adjusted generalized odds ratio [aGenOR] = 1.68, 95% CI: 1.24-2.11, p < 0.001), with no interaction between DHC and treatment (p-interaction = 0.93). At 1 year, 21% of DHC-treated patients were ambulatory; the outcomes were universally poor after early WLST.

Interpretation: In the SELECT2 trial of patients with large ischemic core, DHC was performed in ~1 of 6 patients and early WLST in ~1 of 5 patients, without differences based on treatment with EVT or medical management, nor successful reperfusion. DHC or WLST did not detract from thrombectomy treatment benefit. Additionally, ~20% of patients achieved independent ambulation despite receiving DHC by the 1-year follow-up. The similar distribution of these critical care decisions provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation. ANN NEUROL 2024.

Grants and funding

Stryker Neurovascular