Thrombectomy Shows Benefits in Large-Core Stroke Pretransfer

TOPLINEPatients with acute ischemic stroke with large vessel occlusion (AIS-LVO) and large or very large ischemic cores identified at primary stroke centers (PSCs) before interhospital transfer had better functional outcomes with thrombectomy plus medical management (MM) than with MM alone, a post hoc analysis of the LASTE trial showed.METHODOLOGYA post hoc analysis of the LASTE randomized controlled trial included 157 patients with anterior circulation AIS-LVO (median age, 73 years; 57% men) who had large ischemic cores (Alberta Stroke Program Early CT Score [ASPECTS], 0-5) detected during baseline MRI or CT imaging at a PSC before transfer to a comprehensive stroke center (CSC).Patients received thrombectomy plus MM (intervention group; n = 77) or MM alone (control group; n = 80) within 6.5 hours of last seen well at the CSC. Researchers assessed functional outcomes using the modified Rankin Scale (mRS) score at 90 days post-randomization, with higher scores suggesting greater disability.Key secondary outcomes were the mRS score at 180 days post-randomization, mRS scores of 0-2 and 0-3 at 90 days and 180 days, changes in the ischemic core volumes on CT or MRI between the PSC imaging and 24-hour CSC imaging, and early neurologic improvement (reduction of ≥ 8 points in the National Institutes of Health Stroke Scale score) between CSC admission and day 7 or discharge, whichever came first. All-cause mortality rate at 90 days post-randomization and the occurrence of symptomatic intracerebral hemorrhage within 24 hours post-randomization were assessed as safety outcomes.TAKEAWAYThe intervention group had better functional outcomes than the control group at 90 days, with a shift toward lower mRS scores at 90 days (generalized odds ratio [GenOR], 1.71; P = .002), sustained even at 180 days (GenOR, 1.66; 95% CI, 1.17-2.35).The secondary outcomes were more favorable in the intervention group than in the control group, with a higher proportion of patients with mRS scores of 0-3 at 90 days (31.6% vs 11.4%; relative risk [RR], 2.77; 95% CI, 1.37-5.58) and 180 days (37.3% vs 12.8%; RR, 2.91; 95% CI, 1.52-5.58), a higher proportion of patients with mRS scores of 0-2 at 90 days (10.5% vs 5.1%; RR, 2.08; 95% CI, 0.65-6.62) and 180 days (17.3% vs 5.1%; RR, 3.38; 95% CI, 1.15-9.91), more early neurologic improvement (24.7% vs 5.2%; RR, 4.75; 95% CI, 1.68-13.37), and smaller 24-hour infarct growth (adjusted mean difference in growth, -64 mL; 95% CI, -88 to -40).Mortality at 90 days was lower in the intervention group than in the control group, but the difference was not statistically significant. Symptomatic intracerebral hemorrhage within 24 hours occurred more frequently in the intervention group than in the control group, but the difference was not statistically significant.Thrombectomy showed sustained benefits among patients with very large cores (ASPECTS, 0-2) before transfer (GenOR, 1.87; 95% CI, 1.18-2.94) and among patients who did not undergo repeat imaging at the CSC (GenOR, 1.93; 95% CI, 1.27-2.92). The benefit of thrombectomy in achieving independent ambulation (mRS score, 0-3) declined with longer transfer time, whereas MM outcomes were unaffected by transfer time.IN PRACTICE"These findings support consideration of interhospital transfer for thrombectomy in AIS-LVO patients with large ischemic cores, including ASPECTS of 0 to 2, admitted in PSC in the early time-window, and direct-to-angiosuite protocol on admission at the comprehensive stroke center," the investigators wrote.SOURCEThe study was led by Pierre Seners, MD, PhD, Hôpital Fondation A. de Rothschild, Paris, France. It was published online on September 22 in the Annals of Neurology.LIMITATIONSThe study was limited by a moderate sample size and lack of assessment of the extent of selection bias.DISCLOSURESThe LASTE trial was funded by the Montpellier University Hospital through an unrestricted grant from a consortium of medical device makers, including Balt Extrusion, Cerenovus, Medtronic, MicroVention, and Stryker. The authors reported no relevant conflicts of interest.This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.