Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial
Scott E. Kasner MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMichael T. Mullen MD
Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
Search for more papers by this authorMichael DeGeorgia MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorSpiros Blackburn MD
Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorDonna K. George MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMonisha Kumar MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorSteven Messe MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMichael G. Abraham MD
Department of Neurology, University of Kansas Medical Center, Kansas City, KS
Search for more papers by this authorMichael Chen MD
Department of Neurosurgery, Rush University Medical Center, Chicago, IL
Search for more papers by this authorSantiago Ortega-Gutierrez MD
Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Coralville, IA
Search for more papers by this authorClark W. Sitton MD
Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorJan-Karl Burkhardt MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMuhammad Shazam Hussain MD
Cerebrovascular Center, Department of Neurology, Cleveland Clinic Neurological Institute, Cleveland, OH
Search for more papers by this authorLeonid Churilov PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorSophia Sundararajan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorYin C. Hu MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorNabeel A. Herial MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorPascal Jabbour MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorDaniel Gibson MD
Department of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI
Search for more papers by this authorJuan F. Arenillas MD, PhD
Department of Neurology, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain
Search for more papers by this authorJenny P. Tsai MD
Department of Neurosurgery, Spectrum Health, Grand Rapids, MI
Search for more papers by this authorRonald F. Budzik MD
Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
Search for more papers by this authorWilliam J. Hicks MD
Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
Search for more papers by this authorOsman Kozak MD
Department of Neurosurgery, Abington Jefferson Health, Abington, PA
Search for more papers by this authorBernard Yan MBBS
Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorDennis J. Cordato PhD
Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorNathan W. Manning MBBS
Department of Neurosurgery, Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorMark W. Parsons PhD
Department of Neurology, University of New South Wales-Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorRicardo A. Hanel MD
Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL
Search for more papers by this authorAmin N. Aghaebrahim MD
Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL
Search for more papers by this authorTeddy Y. Wu PhD
Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
Search for more papers by this authorPere Cardona Portela MD
Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
Search for more papers by this authorNatalia Pérez de la Ossa MD, PhD
Department of Neurology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
Search for more papers by this authorJoanna D. Schaafsma MD
Department of Internal Medicine and Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
Search for more papers by this authorJordi Blasco MD, PhD
Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
Search for more papers by this authorNavdeep Sangha MD
Department of Neurology, Kaiser Permanente Southern California, Pasadena, CA
Search for more papers by this authorSteven Warach MD
Department of Neurology, Dell Medical School at The University of Texas at Austin, Austin, TX
Search for more papers by this authorChirag D. Gandhi MD
Department of Neurosurgery, Westchester Medical Center - NY Medical College, New York, NY
Search for more papers by this authorTimothy J. Kleinig PhD
Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
Search for more papers by this authorDaniel Sahlein MD
Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN
Search for more papers by this authorEdgar A. Samaniego MD
Department of Neurology, University of Iowa Hospitals and Clinics, Coralville, IA
Search for more papers by this authorLaith Maali MD
Department of Neurology, University of Kansas Medical Center, Kansas City, KS
Search for more papers by this authorMohammad A. Abdulrazzak MD
Department of Cerebrovascular Diseases, Cleveland Clinic, Cleveland, OH
Search for more papers by this authorKrishna Amuluru MD
Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN
Search for more papers by this authorDeep K. Pujara MBBS
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorFaris Shaker MBChB
Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorHannah Johns PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorRami Moussa BS
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorFaisal Al-Shaibi MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorKelsey R. Duncan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorStavropoula Tjoumakaris MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorAmanda Opaskar MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorWei Xiong MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorAbhishek Ray MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorSepideh Amin-Hanjani MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorThanh N. Nguyen MD
Department of Neurology, Boston Medical Center, Boston, MA
Search for more papers by this authorJohanna T. Fifi MD
Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
Search for more papers by this authorStephen Davis MD
Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorLawrence Wechsler MD
Department of Neurology, Hospitals of University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorAnthony Furlan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorCathy Sila MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorNicholas Bambakidis MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorMichael D. Hill MD
Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorVitor Mendes Pereira MD
Department of Neurology, St. Michael's Hospital, Toronto, Ontario, Canada
Search for more papers by this authorMaarten G. Lansberg MD
Department of Neurology, Stanford University, Stanford, CA
Search for more papers by this authorJames C. Grotta MD
Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX
Search for more papers by this authorMarc Ribo MD
Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain
Search for more papers by this authorGreg W. Albers MD
Department of Neurology, Stanford University, Stanford, CA
Search for more papers by this authorBruce C. Campbell PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne and The Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia
Search for more papers by this authorAmeer E. Hassan DO
Department of Neuroscience, Valley Baptist Medical Center, Brownsville, TX
Search for more papers by this authorCorresponding Author
Amrou Sarraj MD
Department of Neurology and Stroke, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Address correspondence to Dr Amrou Sarraj, University Hospitals Cleveland Medical Center, Hanna House #4, 11100 Euclid Ave, Cleveland, OH 44115. E-mail: [email protected]
Search for more papers by this authorfor the SELECT2 Investigators
Search for more papers by this authorScott E. Kasner MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMichael T. Mullen MD
Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
Search for more papers by this authorMichael DeGeorgia MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorSpiros Blackburn MD
Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorDonna K. George MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMonisha Kumar MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorSteven Messe MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMichael G. Abraham MD
Department of Neurology, University of Kansas Medical Center, Kansas City, KS
Search for more papers by this authorMichael Chen MD
Department of Neurosurgery, Rush University Medical Center, Chicago, IL
Search for more papers by this authorSantiago Ortega-Gutierrez MD
Department of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics, Coralville, IA
Search for more papers by this authorClark W. Sitton MD
Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorJan-Karl Burkhardt MD
Department of Neurology, University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorMuhammad Shazam Hussain MD
Cerebrovascular Center, Department of Neurology, Cleveland Clinic Neurological Institute, Cleveland, OH
Search for more papers by this authorLeonid Churilov PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorSophia Sundararajan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorYin C. Hu MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorNabeel A. Herial MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorPascal Jabbour MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorDaniel Gibson MD
Department of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI
Search for more papers by this authorJuan F. Arenillas MD, PhD
Department of Neurology, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain
Search for more papers by this authorJenny P. Tsai MD
Department of Neurosurgery, Spectrum Health, Grand Rapids, MI
Search for more papers by this authorRonald F. Budzik MD
Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
Search for more papers by this authorWilliam J. Hicks MD
Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
Search for more papers by this authorOsman Kozak MD
Department of Neurosurgery, Abington Jefferson Health, Abington, PA
Search for more papers by this authorBernard Yan MBBS
Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorDennis J. Cordato PhD
Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorNathan W. Manning MBBS
Department of Neurosurgery, Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorMark W. Parsons PhD
Department of Neurology, University of New South Wales-Liverpool Hospital, Liverpool, New South Wales, Australia
Search for more papers by this authorRicardo A. Hanel MD
Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL
Search for more papers by this authorAmin N. Aghaebrahim MD
Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL
Search for more papers by this authorTeddy Y. Wu PhD
Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
Search for more papers by this authorPere Cardona Portela MD
Department of Neurology, Hospital Universitari de Bellvitge, Barcelona, Spain
Search for more papers by this authorNatalia Pérez de la Ossa MD, PhD
Department of Neurology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
Search for more papers by this authorJoanna D. Schaafsma MD
Department of Internal Medicine and Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
Search for more papers by this authorJordi Blasco MD, PhD
Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
Search for more papers by this authorNavdeep Sangha MD
Department of Neurology, Kaiser Permanente Southern California, Pasadena, CA
Search for more papers by this authorSteven Warach MD
Department of Neurology, Dell Medical School at The University of Texas at Austin, Austin, TX
Search for more papers by this authorChirag D. Gandhi MD
Department of Neurosurgery, Westchester Medical Center - NY Medical College, New York, NY
Search for more papers by this authorTimothy J. Kleinig PhD
Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
Search for more papers by this authorDaniel Sahlein MD
Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN
Search for more papers by this authorEdgar A. Samaniego MD
Department of Neurology, University of Iowa Hospitals and Clinics, Coralville, IA
Search for more papers by this authorLaith Maali MD
Department of Neurology, University of Kansas Medical Center, Kansas City, KS
Search for more papers by this authorMohammad A. Abdulrazzak MD
Department of Cerebrovascular Diseases, Cleveland Clinic, Cleveland, OH
Search for more papers by this authorKrishna Amuluru MD
Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, IN
Search for more papers by this authorDeep K. Pujara MBBS
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorFaris Shaker MBChB
Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX
Search for more papers by this authorHannah Johns PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorRami Moussa BS
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorFaisal Al-Shaibi MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorKelsey R. Duncan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorStavropoula Tjoumakaris MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Wayne, PA
Search for more papers by this authorAmanda Opaskar MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorWei Xiong MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorAbhishek Ray MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorSepideh Amin-Hanjani MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorThanh N. Nguyen MD
Department of Neurology, Boston Medical Center, Boston, MA
Search for more papers by this authorJohanna T. Fifi MD
Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
Search for more papers by this authorStephen Davis MD
Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Search for more papers by this authorLawrence Wechsler MD
Department of Neurology, Hospitals of University of Pennsylvania, Philadelphia, PA
Search for more papers by this authorAnthony Furlan MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorCathy Sila MD
Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorNicholas Bambakidis MD
Department of Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Search for more papers by this authorMichael D. Hill MD
Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorVitor Mendes Pereira MD
Department of Neurology, St. Michael's Hospital, Toronto, Ontario, Canada
Search for more papers by this authorMaarten G. Lansberg MD
Department of Neurology, Stanford University, Stanford, CA
Search for more papers by this authorJames C. Grotta MD
Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX
Search for more papers by this authorMarc Ribo MD
Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain
Search for more papers by this authorGreg W. Albers MD
Department of Neurology, Stanford University, Stanford, CA
Search for more papers by this authorBruce C. Campbell PhD
Department of Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne and The Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia
Search for more papers by this authorAmeer E. Hassan DO
Department of Neuroscience, Valley Baptist Medical Center, Brownsville, TX
Search for more papers by this authorCorresponding Author
Amrou Sarraj MD
Department of Neurology and Stroke, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
Address correspondence to Dr Amrou Sarraj, University Hospitals Cleveland Medical Center, Hanna House #4, 11100 Euclid Ave, Cleveland, OH 44115. E-mail: [email protected]
Search for more papers by this authorfor the SELECT2 Investigators
Search for more papers by this authorAbstract
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 2025;97:698–708
Potential Conflicts of Interest
A.S. is the principal investigator of the SELECT and SELECT2 trials, funded by Stryker Neurovascular through grants to University Hospitals Cleveland Medical Center and UT McGovern Medical School. TNN discloses advisory board for Brainomix; Associate Editor of Stroke.
Open Research
Data Availability
Individual patient level data will not be shared. Analysis codes and results will be shared for the purpose of reproducing results after a written request submitted to the corresponding author is reviewed and approved by the steering committee.
Supporting Information
| Filename | Description |
|---|---|
| ana27151-sup-0001-supinfo.docxWord 2007 document , 129.8 KB | Data S1. Supporting Information. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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