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Original Investigation
July 29, 2019

Outcomes of Endovascular Thrombectomy vs Medical Management Alone in Patients With Large Ischemic Cores: A Secondary Analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) Study

Author Affiliations
  • 1Department of Neurology, University of Texas McGovern Medical School, Houston
  • 2Department of Neurology, University of Texas Rio Grande Valley, Harlingen
  • 3Department of Neurology, University of Texas Health Science Center, Neurology, San Antonio
  • 4Department of Radiology, University of Texas Health Science Center, San Antonio
  • 5Department of Radiology, University of Texas McGovern Medical School, Houston
  • 6Department of Neurosurgery, University of Texas McGovern Medical School, Houston
  • 7Clinical and Translational Science, University of Texas McGovern Medical School, Houston
  • 8Department of Biostatistics, University of Alabama at Birmingham
  • 9Department of Neurology, OhioHealth–Riverside Methodist Hospital, Columbus
  • 10Department of Neurology, University of Kansas Medical Center, Kansas City
  • 11Department of Neurology, Emory University, Atlanta, Georgia
  • 12Department of Neurology, Stanford University, Stanford, California
  • 13Department of Neurology, Wellstar Health System, Atlanta, Georgia
JAMA Neurol. Published online July 29, 2019. doi:10.1001/jamaneurol.2019.2109
Key Points

Question  Do patients with large stroke with substantial ischemic changes on imaging achieve reasonable functional and safety outcomes with thrombectomy compared with medical management only?

Findings  This prespecified secondary analysis of a cohort study analyzed 105 patients with substantial ischemic changes on computed tomographic or computed tomographic perfusion imaging, of whom 62 received endovascular thrombectomy. Functional independence was achieved in 31% of patients who received endovascular thrombectomy vs 14% who received medical management only, while deaths, neurological worsening, and symptomatic intracerebral hemorrhage were observed in similar proportions in both groups; also, the likelihood of functional independence declined by 40% with each hour delay and 42% with each 10-cm3 increase in stroke volume.

Meaning  Endovascular thrombectomy may result in therapeutic benefits for patients with large infarcts, especially if they are treated early and have a core volume less than 100 cm3.


Importance  The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge.

Objective  To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone.

Design, Setting, and Participants  This prespecified analysis of the Optimizing Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score <6) or CT perfusion scanning (a volume with a relative cerebral blood flow <30% of ≥50 cm3) were included in analyses.

Exposures  Endovascular thrombectomy with medical management (MM) or MM only.

Main Outcomes and Measures  Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening).

Results  A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome.

Conclusions and Relevance  Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed.