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
{"title":"Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial.","authors":"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","doi":"10.1002/ana.27151","DOIUrl":null,"url":null,"abstract":"<p><strong>Objective: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Interpretation: </strong>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.</p>","PeriodicalId":127,"journal":{"name":"Annals of Neurology","volume":" ","pages":""},"PeriodicalIF":8.1000,"publicationDate":"2024-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Annals of Neurology","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1002/ana.27151","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CLINICAL NEUROLOGY","Score":null,"Total":0}
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 2024.
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.
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