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Observational Study
. 2023 Feb 1;80(2):172-182.
doi: 10.1001/jamaneurol.2022.4714.

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study

Amrou Sarraj  1   2 , Timothy J Kleinig  3 , Ameer E Hassan  4 , Pere Cardona Portela  5 , Santiago Ortega-Gutierrez  6 , Michael G Abraham  7 , Nathan W Manning  8 , James E Siegler  9 , Nitin Goyal  10 , Laith Maali  7 , Spiros Blackburn  11 , Teddy Y Wu  12 , Jordi Blasco  13 , Arturu Renú  13 , Navdeep S Sangha  14 , Juan F Arenillas  15 , Margy E McCullough-Hicks  16 , Adam Wallace  17 , Daniel Gibson  17 , Deep K Pujara  1 , Faris Shaker  11 , Mercedes de Lera Alfonso  15 , Marta Olivé-Gadea  18 , Mudassir Farooqui  19 , Juan S Vivanco Suarez  19 , Zachary Iezzi  9 , Jane Khalife  9 , Colleen G Lechtenberg  7 , Syed K Qadri  20 , Rami B Moussa  1 , Mohammad A Abdulrazzak  21 , Tareq S Almaghrabi  22 , Osman Mir  23 , James Beharry  24 , Balaji Krishnaiah  10 , Megan Miller  25 , Najwa Khalil  25 , Gagan J Sharma  24   26 , Aristeidis H Katsanos  27 , Ali Fadhil  1   2 , Kelsey R Duncan  1   2 , Yin Hu  28 , Sheryl B Martin-Schild  29 , Georgios K Tsivgoulis  30 , Dennis Cordato  25 , Anthony Furlan  1   2 , Leonid Churilov  31 , Peter J Mitchell  32 , Adam S Arthur  33 , Mark W Parsons  25 , James C Grotta  34 , Clark W Sitton  35 , Marc Ribo  18 , Gregory W Albers  36 , Bruce C V Campbell  24
Affiliations
Observational Study

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study

Amrou Sarraj et al. JAMA Neurol. .

Abstract

Importance: The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well.

Objective: To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well.

Design, setting, and participants: This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well.

Interventions: Endovascular thrombectomy or medical management (control).

Main outcomes and measures: Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)-weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts.

Results: Of 301 patients (median [IQR] age, 69 years [59-81]; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P < .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P = .02).

Conclusions and relevance: In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Sarraj reported grants and personal fees from Stryker Neurovascular and personal fees from AstraZeneca outside the submitted work. Dr Hassan reported consultant and/or speaker fees from Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera Therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, and Galaxy Therapeutics outside the submitted work. Dr Ortega-Gutierrez reported grants from Stryker Neurovascular, grants from Methinks, VizIA, National Institutes of Health (NIH), Medtronic, and Microvention and proctor fees from Medtronic and Stryker outside the submitted work. Dr Abraham reported consulting fees from Stryker Neurovascular outside the submitted work. Dr Siegler reported speakers bureau fees from AstraZeneca outside the submitted work. Dr Arenillas reported grants from the Ministry of Science, Spain, and AstraZeneca and personal fees from Medtronic, Boehringer Ingelheim, Amgen, Bayer, BMS-Pfizer, and Daichii-Sankyo outside the submitted work. Dr Wallace reported personal fees from Feldman Shepherd and Robins Kaplan outside the submitted work. Dr Gibson reported personal fees from Siemens Healthineers outside the submitted work. Dr Mitchell reported institutional research support from Stryker Neurovascular and Medtronic outside the submitted work. Dr Arthur reported personal fees from Balt, Cerenovus, Medtronic, Microvention, Penumbra, Scientia, and Stryker and being a shareholder in Bendit, Cerebrotech, and Magneto outside the submitted work. Dr Grotta reported personal fees from Frazer, Haemonetics, Acticor, and Prolong and grants from Genentech, CSL Behring, and Chiesi outside the submitted work. Dr Albers reported consulting fees from and equity in iSchemaView and consulting and other fees from Genentech outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
Patients screened included those with intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack who presented beyond 24 hours after last known well. The control group received medical management only. CT ASPECTS indicates computed tomography Alberta Stroke Program Early CT Score; ICA/M1/M2, internal carotid artery or M1 or M2 segment of the middle cerebral artery; EVT, endovascular thrombectomy; PS, propensity score.
Figure 2.
Figure 2.. Distribution of 90-Day Modified Rankin Scale (mRS) Scores in the Study Population According to Type of Treatment Received
The control group received medical management only. Modified Rankin Scale scores range from 0 to 6 with higher scores indicating worse outcomes.
Figure 3.
Figure 3.. Predicted Probability of Symptomatic Intracranial Hemorrhage (ICH) and Association With Time Between Symptom Onset and Treatment
The graph illustrates the potential increase in the rate of symptomatic ICH as time progresses (P = .06). Shading indicates 95% CIs. SITS-MOST indicates the Safe Implementation of Thrombolysis in Stroke–Monitoring Study.
See this image and copyright information in PMC

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References

    1. Berkhemer OA, Fransen PSS, Beumer D, et al. ; MR CLEAN Investigators . A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20. doi:10.1056/NEJMoa1411587 - DOI - PubMed
    1. Jovin TG, Chamorro A, Cobo E, et al. ; REVASCAT Trial Investigators . Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296-2306. doi:10.1056/NEJMoa1503780 - DOI - PubMed
    1. Goyal M, Demchuk AM, Menon BK, et al. ; ESCAPE Trial Investigators . Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030. doi:10.1056/NEJMoa1414905 - DOI - PubMed
    1. Saver JL, Goyal M, Bonafe A, et al. ; SWIFT PRIME Investigators . Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295. doi:10.1056/NEJMoa1415061 - DOI - PubMed
    1. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. ; EXTEND-IA Investigators . Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018. doi:10.1056/NEJMoa1414792 - DOI - PubMed

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