medwireNews: The addition of endovascular thrombectomy (EVT) to best medical care offers patients who have ischemic stroke with large cores superior functional outcomes at 1 year, shows a prespecified analysis of the SELECT2 trial.
The phase 3 randomized controlled trial, carried out from 2019 to 2022, enrolled patients aged a median of 66.5 years from 31 hospitals in the USA, Canada, Spain, Switzerland, Australia, and New Zealand. The results showed greater improvement in modified Rankin Scale (mRS) score (0–6 points, where a higher score indicates greater disability) at 90 days when patients were given EVT within 24 hours plus best medical care (n=178) rather than best medical care alone (n=174).
All the participants had “ischemic stroke caused by occlusion of the internal carotid artery or of the first part of the middle cerebral artery,” the researchers report, with large ischemic core evident on non-contrast computed tomography (CT) scans (Alberta Stroke Program Early CT Score of 3–5), or measuring 50 mL or more on CT perfusion and magnetic resonance imaging.
The current analysis is based on the 1-year data, which “provide evidence of a durable benefit of endovascular thrombectomy,” say Amrou Sarraj (University Hospital Cleveland Medical Center, Ohio, USA) and colleagues.
Patients who underwent EVT plus medical care were 53% more likely to have better mRS score distribution at 1 year than those receiving medical care alone, after taking into account age, stroke severity, and the size and volume of the ischemic core.
The median mRS score was 5 points among patients receiving EVT compared with 6 points among those in the medical care alone group.
“The number needed to treat for one patient to achieve 1 point or greater improvement in functional outcome on the mRS score with endovascular thrombectomy at 1-year follow-up was 6,” the authors report in The Lancet.
In addition, more patients in the EVT than medical care only group achieved functional independence (mRS = 0–2 points) at 1 year, at 24% versus 6%, as well as independent ambulation (mRS = 0–3 points), at 37% versus 18%.
Neuro-Quality of Life measures showed greater improvements at 1 year with EVT plus medical care versus medical care alone, including significantly better median scores for mobility (40.8 vs 27.2), social health (40.6 vs 35.0), and cognition (46.0 vs 38.9), as well as a nonsignificant lower median depression score (45.3 vs 52.1).
However, there was no significant difference between those receiving and not receiving EVT in all-cause mortality at 1 year, with corresponding rates of 45% and 52%.
In an associated comment, Arturo Consoli (University of Versailles Saint-Quentin-des-Yvelines, Suresnes, France) and Benjamin Gory (Université de Lorraine, Nancy, France) comment on the need for the current findings, given that patients with large ischemic stroke have “high mortality rates and post-stroke disability and […] have been excluded from previous randomized controlled trials,” such as MR CLEAN and REVASCAT.
They conclude: “The stability of the rate of favorable clinical outcomes observed at 1 year shows the consistent and durable benefit of endovascular thrombectomy in patients with large ischemic cores.”
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Lancet 2024; doi:10.1016/ S0140-6736(24)00050-3
Lancet 2024; doi:10.1016/ S0140-6736(24)00158-2