Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 Apr;97(4):698-708.
doi: 10.1002/ana.27151. Epub 2024 Dec 9.

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

Scott E Kasner  1 , Michael T Mullen  2 , Michael DeGeorgia  3 , Spiros Blackburn  4 , Donna K George  1 , Monisha Kumar  1 , Steven Messe  1 , Michael G Abraham  5 , Michael Chen  6 , Santiago Ortega-Gutierrez  7 , Clark W Sitton  8 , Jan-Karl Burkhardt  1 , Muhammad Shazam Hussain  9 , Leonid Churilov  10 , Sophia Sundararajan  3 , Yin C Hu  11 , Nabeel A Herial  12 , Pascal Jabbour  12 , Daniel Gibson  13 , Juan F Arenillas  14 , Jenny P Tsai  15 , Ronald F Budzik  16 , William J Hicks  17 , Osman Kozak  18 , Bernard Yan  19 , Dennis J Cordato  20 , Nathan W Manning  21 , Mark W Parsons  22 , Ricardo A Hanel  23 , Amin N Aghaebrahim  23 , Teddy Y Wu  24 , Pere Cardona Portela  25 , Natalia Pérez de la Ossa  26 , Joanna D Schaafsma  27 , Jordi Blasco  28 , Navdeep Sangha  29 , Steven Warach  30 , Chirag D Gandhi  31 , Timothy J Kleinig  32 , Daniel Sahlein  33 , Edgar A Samaniego  34 , Laith Maali  5 , Mohammad A Abdulrazzak  35 , Krishna Amuluru  33 , Deep K Pujara  3 , Faris Shaker  4 , Hannah Johns  10 , Rami Moussa  3 , Faisal Al-Shaibi  3 , Kelsey R Duncan  3 , Stavropoula Tjoumakaris  12 , Amanda Opaskar  3 , Wei Xiong  3 , Abhishek Ray  11 , Sepideh Amin-Hanjani  11 , Thanh N Nguyen  36 , Johanna T Fifi  37 , Stephen Davis  19 , Lawrence Wechsler  38 , Anthony Furlan  3 , Cathy Sila  3 , Nicholas Bambakidis  11 , Michael D Hill  39 , Vitor Mendes Pereira  40 , Maarten G Lansberg  41 , James C Grotta  42 , Marc Ribo  43 , Greg W Albers  41 , Bruce C Campbell  44 , Ameer E Hassan  45 , Amrou Sarraj  46 ; SELECT2 Investigators
Affiliations
Randomized Controlled Trial

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

Scott E Kasner et al. Ann Neurol. 2025 Apr.

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.

PubMed Disclaimer

References

    1. Sarraj A, Hassan AE, Abraham MG, et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med 2023;10:1259–1271. https://doi.org/10.1056/NEJMoa2214403.
    1. Liebeskind DS, Jüttler E, Shapovalov Y, et al. Cerebral edema associated with large hemispheric infarction. Stroke 2019;50:2619–2625. https://doi.org/10.1161/STROKEAHA.118.024766.
    1. Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009;8:949–958. https://doi.org/10.1016/S1474-4422(09)70224-8.
    1. Hacke W, Schwab S, Horn M, et al. “Malignant” middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996;53:309–315. https://doi.org/10.1001/archneur.1996.00550040037012.
    1. Reinink H, Jüttler E, Hacke W, et al. Surgical decompression for space‐occupying hemispheric infarction: a systematic review and individual patient meta‐analysis of randomized clinical trials. JAMA Neurol 2021;78:208–216. https://doi.org/10.1001/jamaneurol.2020.3745.

Publication types

Grants and funding

LinkOut - more resources