Association of Reperfusion and Procedural Characteristics with Endovascular Thrombectomy Outcomes in Large Core Stroke: Sub‐Analysis from the SELECT2 Trial
Authors: Hassan Ameer E. , Abraham Michael G. , Blackburn Spiros , Hussain Muhammad S. , Ortega‐Gutierrez Santiago , Chen Michael , Hu Yin C. , Pujara Deep K. , Herial Nabeel A. , Tsai Jenny P. , Budzik Ronald F. , Manning Nathan W. , Kozak Osman , Hanel Ricardo A. , Aghaebrahim Amin N. , Gandhi Chirag D. , Al‐Mufti Fawaz , Cheung Andrew , Yan Bernard , Mitchell Peter , Blasco Jordi , Manzanera Luis San Román , Vora Nirav , Gibson Daniel , Wallace Adam , Sahlein Daniel , Elijovich Lucas , Arenillas Juan F. , Wu Teddy Y. , Portela Pere Cardona , de la Ossa Natalia Pérez , Schaafsma Joanna D. , Hicks William J , Cordato Dennis J , Sangha Navdeep , Warach Steven , Kleinig Timothy J , Shaker Faris , Johns Hannah , Tekle Wondwossen , Dannenbaum Mark J. , Ebersole Koji , Toth Gabor , Gooch Michael , Alhajeri Abdulnasser , Amuluru Krishna , Ray Abhishek , Burkhardt Jan‐Karl , Abdulrazzak Mohammad A. , Rosenbaum‐Halevi David P. , Kamal Haris , Duncan Kelsey R. , Sitton Clark W. , Churilov Leonid , Pereira Vitor Mendes , Sunshine Jeffrey , Nguyen Thanh N. , Fifi Johanna T. , Samaniego Edgar A. , Arthur Adam , Tjoumakaris Stavropoula , Jabbour Pascal , Davis Stephen M. , Wechsler Lawrence , Bambakidis Nicholas , Kasner Scott E. , Grotta James C. , Hill Michael D. , Campbell Bruce C. , Ribo Marc , Sarraj Amrou ,   the SELECT2 Trial
Published: November 2024

Endovascular thrombectomy (EVT) was shown to be safe and efficacious in patients with large core stroke in multiple randomized controlled trials. However, the impact of reperfusion and other procedural metrics on EVT outcomes in this population has not been well‐characterized.

Methods

From the SELECT2 trial, we evaluated the association between reperfusion status, first‐pass effect (near‐complete or complete reperfusion [extended thrombolysis in cerebral infarction (eTICI) 2c‐3] in 1 pass), procedure time and primary technique (aspiration vs stent‐retriever) with functional outcomes in patients receiving EVT across ASPECTS (3 vs 4 vs 5) and core estimate strata (<70 vs ≥70ml, <100 vs ≥100ml, and <150 vs ≥150ml).

Results

Of 180 patients who received thrombectomy, 144 (80%) achieved successful reperfusion (eTICI 2b‐3) and demonstrated better clinical outcomes (adjusted generalized odds ratios [aGenOR]: 1.48, 95% confidence interval [CI]: 1.01–2.15), compared with unsuccessful reperfusion. Results were consistent across ASPECTS and core estimate strata. Additionally, complete or near‐complete reperfusion (eTICI 2c‐3) was associated with better functional outcome (aGenOR: 1.99, 95% CI: 1.33–2.97) in patients achieving successful reperfusion. Functional outcome point estimates favored those with first‐pass‐effect (42 of 167 (25%), aGenOR: 1.46, 95% CI: 0.96–2.24). Longer procedure time was associated with worse modified Rankin scale (mRS) distribution (aGenOR: 0.92, 95% CI: 0.87–0.96, p‐value = 0.001 for 10 minutes increment). Aspiration‐first technique was used in 43 of 154 (25%) patients and was not associated with higher reperfusion (88% vs 78%, p = 0.18) or better functional outcome (aGenOR: 0.74, 95% CI: 0.50–1.10) as compared with stent‐retriever first.

Interpretation

Successful reperfusion resulted in improved clinical outcomes in large core patients across baseline ischemic core strata. Near complete or complete reperfusion was further associated with better outcomes, whereas prolonged procedures were associated with worse outcomes. Results were consistent regardless of the technique used. ANN NEUROL 2025;97:175–184