This will ‘change practice’
In a comment, ISC 2023 chair Tudor Jovin, MD, Cooper Neurological Institute, Cherry Hill, N.J., said: “This trial shows that even patients with a large core infarct who we would not have treated with thrombectomy in the past, actually do benefit from this procedure. And the surprise is that the benefit is nearly to the same extent as that in patients with smaller core infarcts. That is going to change practice.”
Dr. Jovin said that these results should not only change the selection of patients for thrombectomy, but they should also change systems of care. “Because the systems of care now are based around excluding these patients with large infarcts. We won’t need to do that in future.”
He elaborated: “I think imaging has held us back to be honest. We can exclude hemorrhage with a plain CT scan. Then after this, the biggest piece of information we need from imaging is the size of the infarct. We were concerned that we might hurt the patient if the infarct was large. Outside hospitals had to do advanced imaging before deciding whether to transfer patients for thrombectomy. These are all sources of delays.
“I am very pleased to see these results, and I hope to see a much more simplified triage of patients that will be more liberal to patients with the large infarcts,” he added.
Also commenting, Joseph Broderick, MD, professor of neurology and director of the Neuroscience Institute at the University of Cincinnati, said the results were “robust and important.”
He said the results of the SELECT2 trial, along with the other two similar trials, “will change practice and extend endovascular therapy to more patients with severe strokes.”
But Dr. Broderick believes imaging will still be necessary to exclude patients with ASPECTS scores of 0-2, who were not included in these trials. “These are patients who have very large areas of clear hypodensity on the baseline image (brain already dying or dead). These patients do not benefit from reperfusion with lytic drugs or endovascular therapy,” he noted.
‘Welcome news’
In an editorial accompanying the print publication of the two new studies, Pierre Fayad, MD, University of Nebraska Medical Center, Omaha, points out that all three trials of thrombectomy in patients with large core infarct strokes “showed remarkably similar results” despite differences in design, patient selection, thrombolytic treatment and dose, geographic location, and imaging criteria.
“Together, the trials provide reassuring information from more than a thousand patients with large ischemic strokes in different medical systems that will probably lead to changes in patterns of care delivery.”
Dr. Fayad said it is reasonable to suggest that endovascular thrombectomy be offered to patients with large strokes if they arrive in a timely fashion at a center that is capable of performing the procedure, and if the patients have an ASPECTS value of 3-5 or an ischemic core volume of 50 mL or greater.
Higher rates of good outcomes may be anticipated if this treatment is performed, despite increased risks of symptomatic hemorrhage, edema, neurologic worsening, and hemicraniectomy, he noted.
“Patients and families should be made aware of the limitations of treatment and the anticipated residual neurologic deficits resulting from the large infarction. The improved chance of independent walking and the ability to perform other daily activities in patients with the most severe strokes is welcome news for patients and for the field of stroke treatment,” he concluded.
The SELECT2 trial was supported by an investigator-initiated grant from Stryker Neurovascular to University Hospitals Cleveland Medical Center and the University of Texas McGovern Medical School.
A version of this article first appeared on Medscape.com.