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

Autor: Kasner SE; Department of Neurology, University of Pennsylvania, Philadelphia, PA., Mullen MT; Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA., DeGeorgia M; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Blackburn S; Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX., George DK; Department of Neurology, University of Pennsylvania, Philadelphia, PA., Kumar M; Department of Neurology, University of Pennsylvania, Philadelphia, PA., Messe S; Department of Neurology, University of Pennsylvania, Philadelphia, PA., Abraham MG; Department of Neurology, University of Kansas Medical Center, Kansas City, KS., Chen M; Department of Neurosurgery, Rush University Medical Center, Chicago, IL., Ortega-Gutierrez S; Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Coralville, IA., Sitton CW; Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX., Burkhardt JK; Department of Neurology, University of Pennsylvania, Philadelphia, PA., Hussain MS; Cerebrovascular Center, Department of Neurology, Cleveland Clinic Neurological Institute, Cleveland, OH., Churilov L; Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia., Sundararajan S; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Hu YC; Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Herial NA; Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA., Jabbour P; Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA., Gibson D; Department of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI., Arenillas JF; Department of Neurology, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain., Tsai JP; Department of Neurosurgery, Spectrum Health, Grand Rapids, MI., Budzik RF; Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH., Hicks WJ; Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH., Kozak O; Department of Neurosurgery, Abington Jefferson Health, Abington, PA., Yan B; Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia., Cordato DJ; Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia., Manning NW; Department of Neurosurgery, Liverpool Hospital, Liverpool, New South Wales, Australia., Parsons MW; Department of Neurology, University of New South Wales-Liverpool Hospital, Liverpool, New South Wales, Australia., Hanel RA; Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL., Aghaebrahim AN; Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL., Wu TY; Department of Neurology, Christchurch Hospital, Christchurch, New Zealand., Portela PC; Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain., de la Ossa NP; Department of Neurology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain., Schaafsma JD; Department of Internal Medicine and Neurology, Toronto Western Hospital, Toronto, Ontario, Canada., Blasco J; Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain., Sangha N; Department of Neurology, Kaiser Permanente Southern California, Pasadena, CA., Warach S; Department of Neurology, Dell Medical School at The University of Texas at Austin, Austin, TX., Gandhi CD; Department of Neurosurgery, Westchester Medical Center - NY Medical College, New York, NY., Kleinig TJ; Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia., Sahlein D; Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN., Samaniego EA; Department of Neurology, University of Iowa Hospitals and Clinics, Coralville, IA., Maali L; Department of Neurology, University of Kansas Medical Center, Kansas City, KS., Abdulrazzak MA; Department of Cerebrovascular Diseases, Cleveland Clinic, Cleveland, OH., Amuluru K; Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN., Pujara DK; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Shaker F; Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX., Johns H; Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia., Moussa R; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Al-Shaibi F; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Duncan KR; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Tjoumakaris S; Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA., Opaskar A; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Xiong W; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Ray A; Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Amin-Hanjani S; Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Nguyen TN; Department of Neurology, Boston Medical Center, Boston, MA., Fifi JT; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY., Davis S; Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia., Wechsler L; Department of Neurology, Hospitals of University of Pennsylvania, Philadelphia, PA., Furlan A; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Sila C; Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Bambakidis N; Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH., Hill MD; Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada., Mendes Pereira V; Department of Neurology, St. Michael's Hospital, Toronto, Ontario, Canada., Lansberg MG; Department of Neurology, Stanford University, Stanford, CA., Grotta JC; Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX., Ribo M; Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain., Albers GW; Department of Neurology, Stanford University, Stanford, CA., Campbell BC; Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne and The Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia., Hassan AE; Department of Neuroscience, Valley Baptist Medical Center, Brownsville, TX., Sarraj A; Department of Neurology and Stroke, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH.
Jazyk: angličtina
Zdroj: Annals of neurology [Ann Neurol] 2024 Dec 09. Date of Electronic Publication: 2024 Dec 09.
DOI: 10.1002/ana.27151
Abstrakt: 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.
(© 2024 American Neurological Association.)
Databáze: MEDLINE
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