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

IF 8.1 1区医学 Q1 CLINICAL NEUROLOGY

Annals of Neurology Pub Date : 2024-12-09 DOI:10.1002/ana.27151

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

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引用次数: 0

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 2025;97:698–708

查看原文本刊更多论文

大核心脑梗死后的关键护理决策：SELECT2试验的二次分析。

目的：在大血管闭塞（LVO）和大缺血核心的患者中，通常需要做出减压半骨切除术（DHC）或早期停止生命维持治疗（WLST）的关键决定。在本研究中，我们旨在评估SELECT2试验中大卒中患者DHC和早期WLST的使用情况及其相关因素。方法：我们分析了整个SELECT2试验人群，其中352例因LVO和大缺血核心导致的卒中患者随机进行血管内血栓切除术（EVT）或药物治疗。我们使用治疗原则来比较随机分组后7天内DHC和早期WLST的使用情况。在做出这些决定后，我们进一步评估功能结果（修正Rankin评分）。结果：352例入组患者中，55例接受DHC治疗，81例过渡到早期WLST。接受EVT治疗的患者发生DHC （16% vs 15%，校正相对风险[aRR] = 1.19, 95% CI:0.75-1.88, p = 0.46）或WLST （22% vs 24%, aRR = 0.94, 95% CI: 0.66-1.34, p = 0.72）的可能性与接受医疗管理的患者相同。年轻患者更常使用DHC，老年患者更常使用WLST。调整DHC后EVT的疗效维持不变（调整广义优势比[aGenOR] = 1.68, 95% CI: 1.24-2.11, p）解释：在SELECT2大缺血核心患者的试验中，6例患者中有1例进行了DHC， 5例患者中有1例进行了早期WLST，没有基于EVT治疗或医疗管理的差异，也没有成功的再灌注。DHC或WLST没有减损取栓治疗的益处。此外，在1年的随访中，约20%的患者在接受DHC治疗后仍能独立行走。这些关键护理决策的相似分布保证了总体试验结果不受开放标签治疗分配的影响。Ann neurol 2024。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Annals of Neurology 医学-临床神经学

CiteScore

18.00

自引率

1.80%

发文量

270

审稿时长

3-8 weeks

期刊介绍： Annals of Neurology publishes original articles with potential for high impact in understanding the pathogenesis, clinical and laboratory features, diagnosis, treatment, outcomes and science underlying diseases of the human nervous system. Articles should ideally be of broad interest to the academic neurological community rather than solely to subspecialists in a particular field. Studies involving experimental model system, including those in cell and organ cultures and animals, of direct translational relevance to the understanding of neurological disease are also encouraged.