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The Endovascular Therapy Train Continues Onward

April 24, 2024

Written by Chris Thom

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This was an exploratory analysis of the recently published SELECT2 trial, which randomized 352 adults with acute ischemic stroke due to carotid or M1 MCA occlusion to endovascular thrombectomy (EVT) or medical management. The current analysis showed that EVT was superior in functional outcomes across a variety of ischemic severities and penumbra profiles on imaging.

EVT is here to stay
This post hoc analysis of the SELECT2 trial sought to explore the EVT treatment effect across a variety of stroke imaging findings. To be enrolled in SELECT2, patients had to have a large infarct core, defined by either noncontrast CT ASPECT score of 3 to 5 or ischemic core volume of ≥50 mL on CT perfusion imaging or diffusion MRI.

EVT improved modified Rankin score functional outcomes within all ASPECT CT categories, with scores of 3 (odds ratio 1.71, 95%CI 1.04-2.81), 4 (OR 2.01, 95%CI 1.19-3.40), and 5 (OR 1.85, 95%CI 1.22-2.79), all showing improved outcomes in the EVT arm. Functional outcomes in the EVT arm were also improved across CT perfusion or MRI ischemic core volumes, with OR 1.63 (95%CI 1.23-2.16) for volumes >70 mL; OR 1.41 (95%CI 0.99-2.02) for volumes >100 mL; and OR 1.47 (95%CI 0.84-2.56) for volumes > 150 mL. The majority of patients had some mismatch (at-risk regions) on imaging, with EVT having improved outcomes in both mismatch and no mismatch patients. Two thirds of patients had MR diffusion follow-up. In this cohort, infarct growth was smaller in patients who had successful EVT reperfusion.  

How will this change my practice?
EVT continues to demonstrate superior outcomes in selected patients with acute ischemic stroke. In the current analysis, the EVT benefit held across a variety of different imaging findings. Prompt consideration for EVT should be undertaken in acute large vessel occlusion events. 

Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles. JAMA. 2024;331(9):750-763. 

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