Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient-Level Analysis from the EXTEND-IA Trials, INSPIRE, and SELECT Studies

Amrou Sarraj; Mark Parsons; Andrew Bivard; Ameer E Hassan; Michael G Abraham; Teddy Wu; Timothy Kleinig; Longting Lin; Chushuang Chen; Christopher Levi; Qiang Dong; Xin Cheng; Ken S Butcher; Philip Choi; Nawaf Yassi; Darshan Shah; Gagan Sharma; Deep Pujara; Faris Shaker; Spiros Blackburn; Helen Dewey; Vincent Thijs; Clark W Sitton; Geoffrey A Donnan; Peter J Mitchell; Bernard Yan; James G Grotta; Gregory W Albers; Stephen M Davis; Bruce Campbell; SELECT Investigators, the EXTEND-IA Investigators, the EXTEND-IA TNK Investigators, the EXTEND-IA TNK Part II Investigators, and the INSPIRE Study Group

doi:10.1002/ana.26331

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient-Level Analysis from the EXTEND-IA Trials, INSPIRE, and SELECT Studies

Ann Neurol. 2022 May;91(5):629-639. doi: 10.1002/ana.26331. Epub 2022 Mar 17.

Authors

Amrou Sarraj^{1

2}, Mark Parsons³, Andrew Bivard^{4

5}, Ameer E Hassan⁶, Michael G Abraham⁷, Teddy Wu⁸, Timothy Kleinig⁹, Longting Lin¹⁰, Chushuang Chen¹⁰, Christopher Levi¹⁰, Qiang Dong¹¹, Xin Cheng¹¹, Ken S Butcher³, Philip Choi¹², Nawaf Yassi^{4

13}, Darshan Shah¹⁴, Gagan Sharma⁴, Deep Pujara², Faris Shaker¹⁵, Spiros Blackburn¹⁵, Helen Dewey¹², Vincent Thijs¹⁶, Clark W Sitton¹⁷, Geoffrey A Donnan⁴, Peter J Mitchell¹⁸, Bernard Yan⁴, James G Grotta¹⁹, Gregory W Albers²⁰, Stephen M Davis⁴, Bruce Campbell⁴; SELECT Investigators, the EXTEND-IA Investigators, the EXTEND-IA TNK Investigators, the EXTEND-IA TNK Part II Investigators, and the INSPIRE Study Group

Affiliations

¹ Case Western Reserve University, Neurology, Cleveland, OH, USA.
² University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³ The University of New South Wales, Neurology, Sydney, New South Wales, Australia.
⁴ The Melbourne Brain Centre, The Royal Melbourne Hospital, University of Melbourne, Neurology, Parkville, Victoria, Australia.
⁵ The University of Newcastle, Stroke and Brain Injury Center, Callaghan, New South Wales, Australia.
⁶ University of Texas Rio Grande Valley - Valley Baptist Medical Center, Neurology, Harlingen, TX, USA.
⁷ University of Kansas Medical Center, Kansas City, KS, USA.
⁸ Christchurch Hospital, Neurology, Christchurch, New Zealand.
⁹ Royal Adelaide Hospital, Neurology, Adelaide, South Australia, Australia.
¹⁰ John Hunter Hospital, University of Newcastle, Neurology, Newcastle, New South Wales, Australia.
¹¹ Huashan Hospital, Fudan University, Neurology, Shanghai, China.
¹² Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
¹³ The Walter and Eliza Hall Institute of Medical Research, Population Health and Immunity Division, Parkville, Victoria, Australia.
¹⁴ Gold Coast University Hospital, Neurology, Southport, Queensland, Australia.
¹⁵ UTHealth McGovern Medical School, Neurosurgery, Houston, TX, USA.
¹⁶ Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia.
¹⁷ UTHealth McGovern Medical School, Diagnostic and Interventional Imaging, Houston, TX, USA.
¹⁸ The Royal Melbourne Hospital, University of Melbourne, Radiology, Parkville, Victoria, Australia.
¹⁹ Memorial Hermann - Texas Medical Center, Neurology, Houston, TX, USA.
²⁰ Stanford University Medical Center, Neurology and Neurological Sciences, Stanford, CA, USA.

PMID: 35184327
DOI: 10.1002/ana.26331

Abstract

Objective: The objective of this study was to evaluate functional and safety outcomes of endovascular thrombectomy (EVT) versus medical management (MM) in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity.

Methods: In a pooled, patient-level analysis of 3 randomized controlled trials (EXTEND-IA, EXTEND-and IA-TNK parts 1 and 2) and 2 prospective nonrandomized studies (INSPIRE and SELECT), we evaluated EVT association with 90-day functional independence (modified Rankin Scale [mRS] = 0-2) in isolated M2 occlusions as compared to medical management overall and in subgroups by mismatch profile status and stroke severity.

Results: We included 517 patients (EVT = 195 and MM = 322), baseline median (interquartile range [IQR]) National Institutes of Health Stroke Scale (NIHSS) was 13 (8-19) in EVT versus 10 (6-15) in MM, p < 0.001. Pretreatment ischemic core did not differ (EVT = 10 [0-24] ml vs MM = 9 [3-21] ml, p = 0.59). Compared to MM, EVT was more frequently associated with functional independence (68.3 vs 61.6%, adjusted odds ratio [aOR] = 2.42, 95% confidence interval [CI] = 1.25-4.67, p = 0.008, inverse probability of treatment weights [IPTW]-OR = 1.75, 95% CI = 1.00-3.75, p = 0.05) with a shift toward better mRS outcomes (adjusted cOR = 2.02, 95% CI:1.23-3.29, p = 0.005), and lower mortality (5 vs 10%, aOR = 0.32, 95% CI = 0.12-0.87, p = 0.025). EVT was associated with higher functional independence in patients with a perfusion mismatch profile (EVT = 70.7% vs MM = 61.3%, aOR = 2.29, 95% CI = 1.09-4.79, p = 0.029, IPTW-OR = 2.02, 1.08-3.78, p = 0.029), whereas no difference was found in those without mismatch (EVT = 43.8% vs MM = 62.7%, p = 0.17, IPTW-OR: 0.71, 95% CI = 0.18-2.78, p = 0.62). Functional independence was more frequent with EVT in patients with moderate or severe strokes, as defined by baseline NIHSS above any thresholds from 6 to 10, whereas there was no difference between groups with milder strokes below these thresholds.

Interpretation: In patients with M2 occlusion, EVT was associated with improved clinical outcomes when compared to MM. This association was primarily observed in patients with a mismatch profile and those with higher stroke severity. ANN NEUROL 2022;91:629-639.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Brain Ischemia* / diagnostic imaging
Brain Ischemia* / surgery
Endovascular Procedures* / methods
Humans
Perfusion Imaging
Prospective Studies
Stroke* / surgery
Thrombectomy / methods
Treatment Outcome