Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial
Authors: Kasner Scott E. , Mullen Michael T. , DeGeorgia Michael , Blackburn Spiros , George Donna K. , Kumar Monisha , Messe Steven , Abraham Michael G. , Chen Michael , Ortega‐Gutierrez Santiago , Sitton Clark W. , Burkhardt Jan‐Karl , Hussain Muhammad Shazam , Churilov Leonid , Sundararajan Sophia , Hu Yin C. , Herial Nabeel A. , Jabbour Pascal , Gibson Daniel , Arenillas Juan F. , Tsai Jenny P. , Budzik Ronald F. , Hicks William J. , Kozak Osman , Yan Bernard , Cordato Dennis J. , Manning Nathan W. , Parsons Mark W. , Hanel Ricardo A. , Aghaebrahim Amin N. , Wu Teddy Y. , Portela Pere Cardona , de la Ossa Natalia Pérez , Schaafsma Joanna D. , Blasco Jordi , Sangha Navdeep , Warach Steven , Gandhi Chirag D. , Kleinig Timothy J. , Sahlein Daniel , Samaniego Edgar A. , Maali Laith , Abdulrazzak Mohammad A. , Amuluru Krishna , Pujara Deep K. , Shaker Faris , Johns Hannah , Moussa Rami , Al‐Shaibi Faisal , Duncan Kelsey R. , Tjoumakaris Stavropoula , Opaskar Amanda , Xiong Wei , Ray Abhishek , Amin‐Hanjani Sepideh , Nguyen Thanh N. , Fifi Johanna T. , Davis Stephen , Wechsler Lawrence , Furlan Anthony , Sila Cathy , Bambakidis Nicholas , Hill Michael D. , Mendes Pereira Vitor , Lansberg Maarten G. , Grotta James C. , Ribo Marc , Albers Greg W. , Campbell Bruce C. , Hassan Ameer E. , Sarraj Amrou ,   for the SELECT2 Investigators
Published: December 2024

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