Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes
Authors: Sarraj Amrou , Hill Michael D. , Hussain M. Shazam , Abraham Michael G. , Ortega-Gutierrez Santiago , Chen Michael , Kasner Scott E. , Churilov Leonid , Pujara Deep K. , Johns Hannah , Blackburn Spiros , Sundararajan Sophia , Hu Yin C. , Herial Nabeel A. , Budzik Ronald F. , Hicks William J. , Arenillas Juan F. , Tsai Jenny P. , Kozak Osman , Cordato Dennis J. , Hanel Ricardo A. , Wu Teddy Y. , Portela Pere Cardona , Gandhi Chirag D. , Al-Mufti Fawaz , Maali Laith , Gibson Daniel , Pérez de la Ossa Natalia , Schaafsma Joanna D. , Blasco Jordi , Sangha Navdeep , Warach Steven , Kleinig Timothy J. , Shaker Faris , Sitton Clark W. , Nguyen Thanh , Fifi Johanna T. , Jabbour Pascal , Furlan Anthony , Lansberg Maarten G. , Tsivgoulis Georgios , Sila Cathy , Bambakidis Nicholas , Davis Stephen , Wechsler Lawrence , Albers Greg W. , Grotta James C. , Ribo Marc , Campbell Bruce C. , Hassan Ameer E. ,   SELECT2 Investigators,   SELECT2 Collaborators, Sarraj Amrou , Sundararajan Sophia , Hu Yin , Sila  Cathy , Furlan  Anthony , Opaskar  Amanda , Bambakidis  Nicholas , Ray  Abhishek , Sunshine  Jeffrey , DeGeorgia Michael , Xiong Wei , Duncan  Rose , Fadhil  Ali , Hansen John , Patel Mohit , Chugh Arunit , Al-Shaibi Faisal , Alomar Majed , El-Azzouni Soheil , Moussa Rami B , Jin Dasul , Nayak Katrina M , Zhang Yiyi , Modak Nikhil S , Jumah Muruj M , Liou Deng-Yuan Dean , Alamoudi Abdullah , Pujara Deep , Blackburn Spiros , Grotta James C. , Sitton Clark , Rahbar Mohammad H , Dannenbaum  Mark , Riascos Roy , Spiegel  Gary , Barreto  Andrew , Sharieff  Anjail , Cochran  Joseph , Day  Arthur L. , Gonzales  Nicole , Reddy  Sujan , Fournier  Lauren , Jones  Erica M , Zelini  Pamela , Kamal  Haris , Castanon Felix  Guerra , Asim Naveed , Shaker Faris , Hessabi Manouchehr , Tahanan Amirali , Abraham Michael , Maali Laith , Ebersole  Koji , Kawano  Jorge , Lechtenberg  Colleen , Slavin  Sabreena , Maali  Latih , Madarang  Ernest , Pendurthi  Aparna , Qureshi  Abid , Reeves  Alan , Rosterman  Lee , Wang  Yunxia , Barkley  Tiffany Thu , Vanguru  Husitha , Paterson  Jeremy , Walters  Carissa , Ackerman  Peyton , Hanel Ricardo , Aghaebrahim Amin N , Sauvageau  Eric , Munden  Gina , Hussain M. Shazam , Abdulrazzak Mohammad A , Uchino  Ken , Katzan  Irene , Lu  Mei , Toth  Gabor , Russman  Andrew , Wisco  Dolora , Sundararajan  Jayashree , Buletko  Andrew , Bain  Mark , Moore  Nina , Witek  Alex , Cierny  Marek , Mahapatra  Ashutosh , Kharal  Ghulum , Limbert  Denice , Resser  Tina , Sweeney  Laura J , Chen Michael , Munich  Stephan , Crowley  Richard , McLaughlin  Elizabeth , Song  Sarah , McWilliams  Rebecca , Jacher  Bartosz , Warach Steven , Milling  Truman J. , Miley  Jefferson , Ellington  Kent , Regan  Aliaksandra , Erfan  Jessica , Mawla  Manzure , Davis  Lisa , Zuck  Nathan , Budzik Ron F , Hicks William J , Vora  Nirav , Pema  Peter , Alhajeri  Abdulnasser , Loochtan  Aaron , Rai  Vivek , Katz  Brian , Koss  Adam , Dedhia Nikita , Groezinger  Katy , Heckathorn  Megan , Bartelt Heather , Sangha Navdeep , Le Duy , Feng Lei  , Chao Kuo , Cheng  Pamela K , Ajani  Zahra A , Lui  Catherine L , Sharma  Ashima , Kozak Osman , Mackenzie Larami , Choe Hana , Bussinger  Patricia , DePalmo  Ashley , Hassan Ameer E , Tekle Wondwossen , Georgiadis Alexandros , Sanchez  Olive , Smith  Pualani , Gibson Daniel , Wallace Adam , Mente Tracy , Wilson Margaret , Ortega-Gutierrez Santiago , Samaniego Edgar , Derdeyn  Colin , Dlouhy  Kathleen , Hasan  David , Hayakawa  Minako , Leira  Enrique , Limaye  Kaustubh , Shaban  Amir , Shim  Hyung Sub , Ghannam  Malik , Zeballos Cynthia , Maljaars Jason , Koul Prateeka , Almajali Mohammad , Olalde  Heena , Kekinagath Harika A , Elijovich Lucas , Arthur  Adam , Hoit  Daniel , Nickele  Christopher , Inoa  Violiza , Goyal  Nitin , Wilson  Stephanie , Parsha  Kaushik , Nolte  Amanda , Herial Nabeel , Jabbour Pascal , Tjoumakaris  Stavropoula , Gooch  Michael Reid , Theofanis   Thana , Rosenwasser  Robert H. , Schunemann Victoria , Tahir Rizwan , Eldin  Mohamed S , Jabre  Roland , Chen  Jared , Jones  Nadirah , Kasner Scott , Cucchiara  Brett L , Messe  Steven Russell , Witsch  Jens , George  Donna , Favilla  Christopher , Yuan  Qingyang , Stein  Laura A , Novello  Paul , Rothstein  Aaron , Cristancho  Daniel , Sloane  Kelly , Humbert  Kelley , Zuflacht  Jonah , Kumar  Arooshi , Khan  Farhan , Mullen  Michael , Dawod  Judy , Burkhardt  Jan-Karl , Jankowitz  Brian , Pukenas  Bryan , Choudhri  Omar , Ramchand  Preethi , Reyes-Esteves  Sahily , Kone  Gbambele , Kvantaliani  Nino , Rosso  Michela , Cole  Sydni , Khazaal  Ossama , Gallatti  Nichole , Tsai Jenny , Min  Jiangyong , Wees  Nabil , Abdallah  Amjad , Khan  Muhib A. , Khan  Nadeem , Ahrar Asad , Mazaris Paul , Malgorzata Miller , Singer Justin , Groseclose Ryan S. , Sultan  Beenish I. , Sahlein Daniel , Amuluru  Krishna , Scott  John , DeNardo  Andrew , Rosenbaum  David , Campbell  Kati , Gandhi Chirag , Al-Mufti  Fawaz , Kaur  Gurmeen , Santarelli Justin , Lemrick  Nicole , Cero  Heather , Clare  Kevin , Nolan  Bridget , Schaafsma Joanna , Stewart Tim , Cayley Anne , Jaigobin Cheryl , Casaubon Leanne , Nicholson Patrick , Agid Ronit , Silver Frank , Pikula Aleksandra , To William , Crellin Lisa , Shuaib Ashfaq , Sobreira Nina , Campbell Bruce C , Yan Bernard , Yogendrakumar Vignan , Ng Felix C , Mitchell Peter J , Dowling Richard J , Bush Steven J , Williams Cameron , Yassi Nawaf , Pavlin-Premrl Davor , Beharry James , Balabanski Anna , Santos Angela Dos , Sharobeam Angelos , Valente Michael , Park Ashley , Wong Joseph , McDonald Amy , Jackson David , Sharma Gagan , Guha Prodipta , Rokaha Birendra , Kleinig Timothy J , Scroop Rebecca , Kurunawai Craig , Mahadevan Joshua , Goh Rudy , Drew Roy , Cordato Dennis , Manning Nathan , Parsons Mark , McQuinn Alex , Wenderoth Jason , Cheung Andrew , McDougall Alan , Thomas James , Cappelen-Smith Cecilia , Blair Christopher , Edwards Leon , Whitely Justin , Helou Jacob , Miller Megan , Wu Teddy Y , Collecutt Wayne , Colgan Frances , Krauss Martin , Laing Andrew , Wilson Duncan , Fink John , LeHeron Campbell , Mason Deborah , Green  Rosemary , Bremner Kathleen , Ribo Marc , Tomasello Alejandro , Requena Ruiz Manuel , Olive Gadea Marta , Sanjuan Estela , Cendrero Judith , Blasco Jordi , Renu Arturo , San Roman Luis , Urra Xabier , Santana Daniel , Maria Cabrera Jose , Llull Laura , López-Rueda Antonio , Cabero Andrea , Serrano Elena , Perez de la Ossa Natalia , Hernández-Pérez Maria , Millán Mònica , Gomis Meritxell , Bustamante Alejandro , Dorado Laura , Gómez-Choco Manuel , Remollo Sebastià , Castaño Carlos , Werner Mariano , Muñoz-Narbona Lucia , Cardona Pere , Quesada Helena , Lara Blanca , Paipa Andres , Nuñez Anna , Cuba Victor , Chirife Oscar , Aja Lucia , de Miquel Maria Angeles , Arenillas Juan F , De Lera Alfonso Mercedes , Araque María Esther Ramos , Calleja Ana I , Cortijo Elisa , Martínez-Galdámez Mario , Schüller Miguel , Galván Jorge , Reyes Muñoz Javier , Vicente Gómez Beatriz , Psychogios Marios , Brehm Alex , Vora Nirav , Manning Nathan W. , Cheung Andrew , Aghaebrahim Amin N. , Paipa Merchán Andres J. , Sahlein Daniel , Requena Ruiz Manuel , Elijovich Lucas , Arthur Adam , Al-Shaibi Faisal , Samaniego Edgar A. , Duncan Kelsey R. , Opaskar Amanda , Ray Abhishek , Xiong Wei , Sunshine Jeffery , DeGeorgia Michael , Tjoumakaris Stavropoula , Mendes Pereira Vitor 
Published: February 2024

Importance

Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT).

Objective

To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes.

Design, Setting, and Participants

This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024.

Interventions

EVT vs MM.

Main Outcomes and Measures

Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication.

Results

A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80).

Conclusions and Relevance

Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport.

Trial Registration

ClinicalTrials.gov Identifier: NCT03876457