大面积核心脑梗死的重症监护决策：SELECT2试验的二次分析

Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial.

作者信息

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

机构信息

Department of Neurology, University of Pennsylvania, Philadelphia, PA.

Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.

出版信息

Ann Neurol. 2025 Apr;97(4):698-708. doi: 10.1002/ana.27151. Epub 2024 Dec 9.

DOI:10.1002/ana.27151

PMID:39648975

Abstract

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.

摘要

目的

在患有大血管闭塞（LVO）和大面积缺血核心区的患者中，常常需要就减压性颅骨切除术（DHC）或早期撤除维持生命治疗（WLST）做出关键决策。在本研究中，我们旨在评估SELECT2试验中大面积卒中患者DHC和早期WLST的使用情况及其相关因素。

方法

我们分析了整个SELECT2试验人群，该试验将352例因LVO和大面积缺血核心区导致卒中的患者随机分为血管内血栓切除术（EVT）组或药物治疗组。我们采用实际治疗原则比较随机分组后7天内DHC和早期WLST的使用情况。我们还进一步评估了这些决策后的功能结局（改良Rankin评分）。

结果

在本研究纳入的352例患者中，55例接受了DHC，81例转为早期WLST。接受EVT治疗的患者接受DHC（16%对15%，调整后相对风险[aRR]=1.19，95%CI：0.75-1.88，p=0.46）或WLST（22%对24%，aRR=0.94，95%CI：0.66-1.34，p=0.72）的可能性与接受药物治疗的患者相似。DHC在年轻患者中使用更频繁，WLST在老年患者中使用更频繁。调整DHC后，EVT疗效得以维持（调整后广义优势比[aGenOR]=1.68，95%CI：1.24-2.11，p<0.001），DHC与治疗之间无相互作用（p-相互作用=0.93）。1年时，21%接受DHC治疗的患者能够行走；早期WLST后的结局普遍较差。

解读

在SELECT2试验的大面积缺血核心区患者中，约6例患者中有1例接受了DHC，约5例患者中有1例接受了早期WLST，无论采用EVT治疗还是药物治疗，以及是否成功再灌注，均无差异。DHC或WLST并未削弱血栓切除术的治疗益处。此外，到1年随访时，尽管接受了DHC，但仍有~20%的患者实现了独立行走。这些重症监护决策的相似分布让人放心，即总体试验结果没有因开放标签治疗分配而产生偏差。《神经病学纪事》2025年；97：698-708。