Study Evaluates the Impact of Thrombectomy in Individuals with Large Infarct Detected by Noncontrast CT

In results of a study published in JAMA Neurology, thrombectomy did not improve functional outcomes at 90 days in individuals with anterior circulation, large-vessel occlusion, and large infarct detected by noncontrast CT scan within 24 hours of onset. These findings have important implications because although noncontrast CT is the most common stroke imaging approach, recent trials involving large infarct thrombectomy used heterogeneous imaging modalities and time windows for participant selection.

The open-label, blinded-end point, bayesian-adaptive randomized TESLA clinical trial (NCT03805308) included 300 participants from 47 stroke thrombectomy centers in the United States who had anterior-circulation, large-vessel occlusion and large infarcts on noncontrast CT scans, with Alberta Stroke Program Early CT Scores of 2 to 5. Participants were randomized to either undergo endovascular treatment using standard thrombectomy devices and usual medical care (intervention group; n=152) or usual medical care alone (control group; n=148). The primary efficacy endpoint was improvement in 90-day functional outcome, measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores.

• Mean 90-day UW-mRS score was 2.93 for the intervention group vs 2.27 for the control group (adjusted difference, 0.63; 95% credible interval [CrI], -0.09 to 1.34).
• 90-day mortality was 35.3% for the intervention group vs 33.3% for the control group.
• 24-hour symptomatic intracranial hemorrhage was experienced by 4.0% of individuals in the intervention group vs 1.3% in the control group.
• Parenchymal hematoma type 2 hemorrhages were experienced by 9.5% of individuals in the intervention group vs 3.4% in the control group.
• Subarachnoid hemorrhages were experienced by 16.2% of individuals in the intervention group vs 6.2% in the control group.

The study authors noted that additional studies may be needed to determine the potential role of thrombectomy in this context because the width of the credible interval around the effect estimate has the possibility of having both no important effect and a clinically relevant benefit.