Thrombectomy promising for Stroke with Large Infarct of Unrestricted Size, unravels study

The LASTE trial showed that thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage in patients with acute stroke and a large infarct of unrestricted size.

"At 90 days, the median modified Rankin scale score was 4, indicating moderately severe disability, in the thrombectomy group versus 6 in the control group, indicating death (generalized OR 1.63)," the researchers reported in the New England Journal of Medicine. Scores of 5 and 6 were combined into one score in the analysis.

Death from any cause occurred in 36.1% of patients in the thrombectomy group compared with 55.5% of those in the control group (adjusted relative risk [aRR] 0.65, 95% CI 0.50-0.84) at 90 days. The benefits of thrombectomy were sustained at 180 days.

The trial, meticulously designed and executed with precision, sought to address a critical gap in stroke management: the lack of effective treatment options for patients with large infarcts of unrestricted size. Traditional thrombectomy procedures have typically been deemed ineffective or risky in such cases, leaving healthcare providers grappling with limited therapeutic avenues and patients facing bleak prognoses.

Caroline Arquizan, MD, of the Hôpital Gui de Chauliac in Montpellier, France, and colleagues aimed to investigate the use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size.

For this purpose, the researchers included patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging (MRI) or computed tomography within 6.5 hours after symptom onset. They were randomized in a 1:1 ratio to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or medical care alone (control group).

The study's primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores suggesting greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage.

Three hundred and thirty-three patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); because of consent withdrawal or legal reasons, 9 were excluded from the analysis.

The researchers reported the following findings:

• The trial was stopped early because the results of similar trials favored thrombectomy.
• Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63).
• Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and 55.5% of those in the control group (adjusted relative risk, 0.65), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73).
• Eleven procedure-related complications occurred in the thrombectomy group.

The findings showed that in patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in lower mortality and better functional outcomes than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage.

Reference:

Costalat V, et al "Trial of thrombectomy for stroke with a large infarct of unrestricted size" N Engl J Med 2024; DOI: 10.1056/NEJMoa2314063