SELECT2: A Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke

Study Overview
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Brief Summary
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SELECT 2 evaluates the efficacy and safety of endovascular thrombectomy compared to medical management alone in acute ischemic stroke patients due to a large vessel occlusion in the distal ICA and MCA M1 who have large core on either CT (ASPECTS: 3-5) or advanced perfusion imaging ([rCBF<30%] on CTP or [ADC<620] on MRI: ≥50cc) or both and are treated within 0-24 hours from last known well.

Detailed Description
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SELECT 2 is a prospective, phase III randomized, international, multicenter, assessor-blinded controlled trial evaluating the efficacy and safety of thrombectomy in patients with large core on either CT or advanced perfusion imaging treated within 0-24 hours from last known well. Patients with the final diagnosis of an acute ischemic stroke due to a large vessel occlusion in the distal ICA and MCA M1 who have large core on either CT (ASPECTS: 3-5) or advanced perfusion imaging ([rCBF<30%] on CTP or [ADC<620] on MRI: ≥50cc) or both within 0-24 hrs from last known well will be randomized in a 1:1 ratio into thrombectomy plus medical management vs medical management alone. Patient outcomes will be measured at baseline, 24 hours post, discharge, 30 days and 90 days. The primary endpoint is the Modified Rankin Scale (mRS) at 90 (+/- 15) days. The primary outcome is a shift on 90-day mRS. Secondary outcomes are favorable clinical outcomes: mRS score of 0-2, safety outcomes such the incidence of symptomatic intracranial hemorrhage (sICH per SITS-MOST) and Imaging endpoints such as infarct volume on MRI diffusion-weighted imaging (DWI) sequence (or CT if MRI not feasible) 24 to 72 hours after randomization. CT images will be read by iSchemaView automated ASPECTS as well as by a physician. In cases where there is disagreement, the physician reading will override the automated software reading. CT/MR perfusion images with mismatch determination will be read by iSchemaView automated RAPID software. All the images will be adjudicated by a blinded core lab at the University of Texas-Medical School at Houston. A maximum of 560 patients will be randomized across the study sites. Covariate adaptive randomization will be used to balance the distribution of important variables. Interim analyses will be conducted at 200 and 380 patients, at which time the study may stop for efficacy or futility.

Official Title
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SELECT2: A Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke

Conditions
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Acute Ischemic Stroke

Intervention / Treatment
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* Device: Endovascular Thrombectomy
* Other: Medical Management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults (18-85 years) with the final diagnosis of an acute ischemic stroke NIH Stroke Scale Score (NIHSS) ≥ 6 Last known well to groin puncture or medical management between 0 to 24 hours Pre-stroke modified Rankin Scale score (mRS) of 0-1 Eligible for thrombectomy or medical management Signed Informed Consent obtained Subject willing to comply with the protocol follow-up requirements Anticipated life expectancy of at least 3 months Specific Neuroimaging Inclusion Criteria: Proven large vessel occlusion in ICA or MCA-M1 occlusion (carotid occlusions can be cervical or intracranial, with or without tandem MCA lesions) determined by MRA or CTA Large infarct-core lesion on at least one of the following: 2.1. Non-Contrast CT (ASPECTS of 3-5), 2.2. CT perfusion (rCBF<30% ≥50cc), 2.3. MRI-DWI (ADC<620 ≥50cc) Exclusion Criteria: Inability to undergo CT angiography and/or CT perfusion imaging (e.g., renal insufficiency, iodine/contrast allergy) Co-morbid psychiatric or medical illnesses that would confound the neurological assessments Treatment with thrombolytic agent beyond 4.5 hours from last known well Treated with thrombolytic agent 3-4.5 hours after last known well AND any of the following: 1) age >80, 2) current anticoagulant use, 3) history of diabetes AND prior stroke, 4) NIHSS >25, 5) ischemic involvement of > 1/3 MCA territory Current participation in another investigational drug or device study. Neuroimaging Exclusion Criteria Patients who have both ASPECTS of 6-10 on non-contrast CT AND core volume <50 cc on perfusion imaging Patients with very large core on non-contrast CT i.e. ASPECTS ≤ 2 Evidence of intracranial tumor (except small meningioma), acute intracranial hemorrhage, neoplasm, or arteriovenous malformation A significant mass effect with midline shift Evidence of internal carotid artery dissection that is flow limiting or aortic dissection Intracranial stent implanted in the same vascular territory that precludes the safe deployment/removal of the neurothrombectomy device Acute symptomatic arterial occlusions in more than one vascular territory confirmed on CTA/MRA (e.g., bilateral MCA occlusions, or an MCA and a basilar artery occlusion). Signs of established infarct and large area of cerebral edema on non-contrast CT

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Endovascular Thrombectomy plus Medical Management<br> | Device: Endovascular Thrombectomy<br>* Patients randomized to endovascular thrombectomy arm will receive thrombectomy plus medical management. They will be treated with thrombectomy devices (stent-retrievers or aspiration devices) currently cleared by the FDA for thrombus removal in patients experiencing an acute stroke within 24 hours of symptom onset. The devices which will be used are FDA-approved stent retrievers: the Trevo Retriever, the Solitaire Revascularization Device, EmboTrap Revascularization Device and Tigertriever Revascularization Device; and/or the aspiration devices approved by the FDA (e.g. MicroVention SOFIA Catheter, and the Penumbra thrombectomy system). The choice of thrombectomy method, primary approach/technique, whether primary aspiration or primary stent-retriever with or without aspiration, will be left up to the interventionalist, with any of the FDA-approved devices approved in the study protocol or a combination of them.<br>Other: Medical Management<br>* Patients will receive standard AHA guideline-directed medical therapy, which will include IV thrombolytic therapy available for use according to practice guidelines in patients presenting within the first 3 hours from last-seen-normal and meeting other FDA label criteria, or up to 4.5 hours from last-seen-normal and meeting other AHA guidelines. For non-thrombolysis treated patients, this will include aspirin 325 mg on day 1 followed by aspirin 81 mg or 325 mg thereafter, which will be determined by treating physician and standard deep venous thrombosis prevention therapy. Intravenous anticoagulation and dual anti-platelet therapy will be discouraged without clear documented reasoning. Post-thrombolysis patients will be treated based on standard study site protocols for these patients.<br>|
| Active Comparator: Medical Management<br> | Other: Medical Management<br>* Patients will receive standard AHA guideline-directed medical therapy, which will include IV thrombolytic therapy available for use according to practice guidelines in patients presenting within the first 3 hours from last-seen-normal and meeting other FDA label criteria, or up to 4.5 hours from last-seen-normal and meeting other AHA guidelines. For non-thrombolysis treated patients, this will include aspirin 325 mg on day 1 followed by aspirin 81 mg or 325 mg thereafter, which will be determined by treating physician and standard deep venous thrombosis prevention therapy. Intravenous anticoagulation and dual anti-platelet therapy will be discouraged without clear documented reasoning. Post-thrombolysis patients will be treated based on standard study site protocols for these patients.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Modified Rankin Scale (mRS) score | The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with 0 being perfect health without symptoms to 6 being death. Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms. Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent. Score 6: Dead | baseline, 90 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Functional independence, defined as mRS score of 0-2 at 90-day follow-up | The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with 0 being perfect health without symptoms to 6 being death. Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms. Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent. Score 6: Dead | 90 days | 
| Independent ambulation, defined as mRS score of 0-3 at 90-day follow-up | The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with 0 being perfect health without symptoms to 6 being death. Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms. Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent. Score 6: Dead | 90 days | 
| Symptomatic intracranial hemorrhage (sICH) as measured by the SITS-MOST criteria |  | 24 hours | 
| Neurological worsening defined as a ≥4-point increase on the NIHSS score due to the stroke itself |  | 24 hours | 
| Mortality within 90-day follow-up |  | 90 days | 
| Procedural complications | Surgical site hematoma Surgical site infection Vascular injury (peripheral or intracranial dissection, perforation or others) caused by the endovascular procedure | 24 hours | 
| Successful reperfusion in the EVT group, defined as modified Thrombolysis in Cerebral Ischemia (mTICI) grade of 2b or higher |  | at the end of endovascular thrombectomy procedure | 
| Discharge location |  | day 5-7 after randomization/at discharge (whichever is later) | 
| Early neurological improvement, defined as improvement of ≥8 points on NIHSS at 24 hours of presentation or an NIHSS of 0-1 |  | 24 hours | 
| Quality of life score, as measured using NeuroQOL at 90-day follow-up |  | 90 days | 
| The 1-year functional outcome, as measured by the modified Rankin Scale score |  | 1 year | 
| Functional independence, defined as mRS score of 0-2 at 1-year follow-up |  | 1 year | 
| Independent ambulation, defined as mRS score of 0-3 at 1-year follow-up |  | 1 year | 
| Quality of life score, as measured using NeuroQOL at 1 year follow-up |  | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Ischemic stroke, Large vessel occlusion, Endovascular thrombectomy