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

Area of Science:

• Neurology
• Critical Care Medicine
• Stroke Research

Background:

• Large vessel occlusion (LVO) strokes with large ischemic cores present complex treatment decisions.
• Decompressive hemicraniectomy (DHC) and withdrawal of life-sustaining therapy (WLST) are critical interventions in these severe stroke cases.

Purpose of the Study:

• To evaluate the utilization of DHC and early WLST in patients with large strokes from the SELECT2 trial.
• To identify factors associated with DHC and early WLST decisions.
• To assess the impact of DHC and WLST on functional outcomes and endovascular thrombectomy (EVT) efficacy.

Main Methods:

• Analysis of the entire SELECT2 trial population (352 patients) with LVO and large ischemic cores.
• Comparison of DHC and early WLST use within 7 days post-randomization between EVT and medical management groups.
• Assessment of functional outcomes using the modified Rankin Score at 1 year.

Main Results:

• DHC was performed in approximately 16% and early WLST in 22-24% of patients.
• Utilization of DHC and WLST did not differ significantly between EVT and medical management groups.
• DHC was more common in younger patients, while WLST was more frequent in older patients.
• EVT efficacy was maintained after adjusting for DHC, with no interaction effect.
• At 1 year, 21% of DHC patients were ambulatory; outcomes after early WLST were poor.

Conclusions:

• DHC and early WLST are utilized in a significant proportion of LVO stroke patients with large ischemic cores.
• These interventions are applied similarly across EVT and medical management strategies.
• DHC does not negate the benefits of EVT, and a subset of patients achieve functional independence.
• The consistent application of DHC and WLST across treatment arms supports the trial's outcome validity.