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Thrombectomy for Stroke With Large Infarct on Noncontrast CT
Quick Takes
- The 2023 SELECT2 and ANGEL-ASPECT trials showed a benefit for thrombectomy over medical management for stroke patients with large vessel occlusion (LVO) and large infarct who could be treated within 24 hours of last known normal, with individual patient eligibility often requiring consideration of core volume based on CT perfusion or MRI.
- The TESLA trial was pragmatic in design, evaluating the role of thrombectomy in patients with LVO and large infarct who could be treated within 24 hours of last known normal, selected by noncontrast head CT only.
- The TESLA trial did not find a significant benefit of thrombectomy for this patient population, a result that will likely be surprising to some stroke providers coming on the heels of the positive SELECT2, ANGEL-ASPECT, and TENSION trials.
Study Questions:
Is thrombectomy superior to medical management alone in patients with anterior circulation large vessel occlusion (LVO) and large infarct on noncontrast head computed tomography (NCHCT) only who can be treated within 24 hours of last known normal?
Methods:
TELSA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke) was a pragmatic randomized controlled trial with open-label treatment and blinded endpoint assessment. Patients were 18-85 years of age, presented within 24 hours of last known normal, had a National Institutes of Health Stroke Scale (NIHSS) score of ≥6, had an anterior circulation LVO, and had a large infarct on NCHCT (determined by Alberta Stroke Program Early CT Score [ASPECTS] scale). Patients were randomized 1:1 to usual medical care or thrombectomy plus usual medical care. The primary outcome was the mean score on the utility-weighted modified Rankin scale (mRS) score at 90 days. The primary safety event endpoint was 90-day all-cause mortality.
Results:
A total of 152 (50.7%) patients were assigned to the thrombectomy group and 148 (49.3%) patients to the medical group. The utility-weighted mRS was not significantly higher (better) in the thrombectomy group compared to the medical group. No significant difference in 90-day all-cause mortality was found.
Conclusions:
The TESLA trial did not show a significant benefit of thrombectomy over medical management for patients with large infarct identified by NCHCT alone who presented within 24 hours of last known normal.
Perspective:
The authors hypothesize that TESLA was negative where other large core trials were positive because of the longer time from last known normal to randomization in TESLA compared to the time intervals in the other trials. TESLA did not show a significant effect modification by early (0-6 hours) versus late (>6-24 hours) presentation, but the point estimate of benefit was reduced in the later window. The 2023 TENSION trial had a similarly pragmatic (NCHCT only) design and did find a benefit in patients with large core and anterior circulation LVO who were treated within 12 hours of last known normal. Stroke investigators will continue to study expanded patient populations who may benefit from thrombectomy, such as patients beyond 24 hours from last known normal, patients with very large core infarct volumes (>100 mL), patients >80 years of age, and patients with baseline disability.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine
Keywords: Computed Tomography, Stroke, Thrombectomy
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