SELECT2: A Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT2)

• ClinicalTrials.gov Identifier: NCT03876457
• Recruitment Status: Active, not recruiting
• First Posted: March 15, 2019
• Last Update Posted: December 12, 2022
• Sponsor: University Hospitals Cleveland Medical Center
• Collaborators: Stryker Neurovascular; The University of Texas Health Science Center, Houston
• Information provided by (Responsible Party): Amrou Sarraj, University Hospitals Cleveland Medical Center

Study Description

Brief Summary:

SELECT 2 evaluates the efficacy and safety of endovascular thrombectomy compared to medical management alone in acute ischemic stroke patients due to a large vessel occlusion in the distal ICA and MCA M1 who have large core on either CT (ASPECTS: 3-5) or advanced perfusion imaging ([rCBF<30%] on CTP or [ADC<620] on MRI: ≥50cc) or both and are treated within 0-24 hours from last known well.

Condition or disease	Intervention/treatment	Phase
Acute Ischemic Stroke	Device: Endovascular Thrombectomy; Other: Medical Management	Not Applicable

Detailed Description:

SELECT 2 is a prospective, phase III randomized, international, multicenter, assessor-blinded controlled trial evaluating the efficacy and safety of thrombectomy in patients with large core on either CT or advanced perfusion imaging treated within 0-24 hours from last known well.

Patients with the final diagnosis of an acute ischemic stroke due to a large vessel occlusion in the distal ICA and MCA M1 who have large core on either CT (ASPECTS: 3-5) or advanced perfusion imaging ([rCBF<30%] on CTP or [ADC<620] on MRI: ≥50cc) or both within 0-24 hrs from last known well will be randomized in a 1:1 ratio into thrombectomy plus medical management vs medical management alone. Patient outcomes will be measured at baseline, 24 hours post, discharge, 30 days and 90 days.

The primary endpoint is the Modified Rankin Scale (mRS) at 90 (+/- 15) days. The primary outcome is a shift on 90-day mRS. Secondary outcomes are favorable clinical outcomes: mRS score of 0-2, safety outcomes such the incidence of symptomatic intracranial hemorrhage (sICH per SITS-MOST) and Imaging endpoints such as infarct volume on MRI diffusion-weighted imaging (DWI) sequence (or CT if MRI not feasible) 24 to 72 hours after randomization. CT images will be read by iSchemaView automated ASPECTS as well as by a physician. In cases where there is disagreement, the physician reading will override the automated software reading. CT/MR perfusion images with mismatch determination will be read by iSchemaView automated RAPID software. All the images will be adjudicated by a blinded core lab at the University of Texas-Medical School at Houston.

A maximum of 560 patients will be randomized across the study sites. Covariate adaptive randomization will be used to balance the distribution of important variables. Interim analyses will be conducted at 200 and 380 patients, at which time the study may stop for efficacy or futility.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 352 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Single (Outcomes Assessor)
• Primary Purpose: Treatment
• Official Title: SELECT2: A Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke
• Actual Study Start Date: October 11, 2019
• Actual Primary Completion Date: November 20, 2022
• Estimated Study Completion Date: December 31, 2023

Arms and Interventions

Arm	Intervention/treatment
Experimental: Endovascular Thrombectomy plus Medical Management	Device: Endovascular Thrombectomy; Patients randomized to endovascular thrombectomy arm will receive thrombectomy plus medical management. They will be treated with thrombectomy devices (stent-retrievers or aspiration devices) currently cleared by the FDA for thrombus removal in patients experiencing an acute stroke within 24 hours of symptom onset. The devices which will be used are FDA-approved stent retrievers: the Trevo Retriever, the Solitaire Revascularization Device, EmboTrap Revascularization Device and Tigertriever Revascularization Device; and/or the aspiration devices approved by the FDA (e.g. MicroVention SOFIA Catheter, and the Penumbra thrombectomy system). The choice of thrombectomy method, primary approach/technique, whether primary aspiration or primary stent-retriever with or without aspiration, will be left up to the interventionalist, with any of the FDA-approved devices approved in the study protocol or a combination of them.; Other: Medical Management; Patients will receive standard AHA guideline-directed medical therapy, which will include IV thrombolytic therapy available for use according to practice guidelines in patients presenting within the first 3 hours from last-seen-normal and meeting other FDA label criteria, or up to 4.5 hours from last-seen-normal and meeting other AHA guidelines. For non-thrombolysis treated patients, this will include aspirin 325 mg on day 1 followed by aspirin 81 mg or 325 mg thereafter, which will be determined by treating physician and standard deep venous thrombosis prevention therapy. Intravenous anticoagulation and dual anti-platelet therapy will be discouraged without clear documented reasoning. Post-thrombolysis patients will be treated based on standard study site protocols for these patients.
Active Comparator: Medical Management	Other: Medical Management; Patients will receive standard AHA guideline-directed medical therapy, which will include IV thrombolytic therapy available for use according to practice guidelines in patients presenting within the first 3 hours from last-seen-normal and meeting other FDA label criteria, or up to 4.5 hours from last-seen-normal and meeting other AHA guidelines. For non-thrombolysis treated patients, this will include aspirin 325 mg on day 1 followed by aspirin 81 mg or 325 mg thereafter, which will be determined by treating physician and standard deep venous thrombosis prevention therapy. Intravenous anticoagulation and dual anti-platelet therapy will be discouraged without clear documented reasoning. Post-thrombolysis patients will be treated based on standard study site protocols for these patients.

Outcome Measures

Primary Outcome Measures :

1. Change in Modified Rankin Scale (mRS) score [ Time Frame: baseline, 90 days ]

   The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with "0" being perfect health without symptoms to "6" being death.

   Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms.

   Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

   Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

   Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

   Score 6: Dead

Secondary Outcome Measures :

1. Functional independence, defined as mRS score of 0-2 at 90-day follow-up [ Time Frame: 90 days ]

   The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with "0" being perfect health without symptoms to "6" being death.

   Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms.

   Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

   Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

   Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

   Score 6: Dead

2. Independent ambulation, defined as mRS score of 0-3 at 90-day follow-up [ Time Frame: 90 days ]

   The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The scale runs from 0-6 with "0" being perfect health without symptoms to "6" being death.

   Score 0: No symptoms Score 1: No significant disability. Able to carry out all usual activities, despite some symptoms.

   Score 2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

   Score 3: Moderate disability. Requires some help, but able to walk unassisted. Score 4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

   Score 5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

   Score 6: Dead

3. Symptomatic intracranial hemorrhage (sICH) as measured by the SITS-MOST criteria [ Time Frame: 24 hours ]
4. Neurological worsening defined as a ≥4-point increase on the NIHSS score due to the stroke itself [ Time Frame: 24 hours ]
5. Mortality within 90-day follow-up [ Time Frame: 90 days ]
6. Procedural complications [ Time Frame: 24 hours ]
   • Surgical site hematoma
   • Surgical site infection
   • Vascular injury (peripheral or intracranial dissection, perforation or others) caused by the endovascular procedure
7. Successful reperfusion in the EVT group, defined as modified Thrombolysis in Cerebral Ischemia (mTICI) grade of 2b or higher [ Time Frame: at the end of endovascular thrombectomy procedure ]
8. Discharge location [ Time Frame: day 5-7 after randomization/at discharge (whichever is later) ]
9. Early neurological improvement, defined as improvement of ≥8 points on NIHSS at 24 hours of presentation or an NIHSS of 0-1 [ Time Frame: 24 hours ]
10. Quality of life score, as measured using NeuroQOL at 90-day follow-up [ Time Frame: 90 days ]
11. The 1-year functional outcome, as measured by the modified Rankin Scale score [ Time Frame: 1 year ]
12. Functional independence, defined as mRS score of 0-2 at 1-year follow-up [ Time Frame: 1 year ]
13. Independent ambulation, defined as mRS score of 0-3 at 1-year follow-up [ Time Frame: 1 year ]
14. Quality of life score, as measured using NeuroQOL at 1 year follow-up [ Time Frame: 1 year ]

Other Outcome Measures:

1. Infarct volume on MRI DWI sequence (or CT if MRI not feasible) 24 hours to 7 days after randomization [ Time Frame: 24 hours to 7 days ]
2. Lesion growth between the ischemic core on baseline imaging and the follow-up infarct volume [ Time Frame: 24 hours to 7 days ]
3. Parenchymal Hemorrhage type 2 [ Time Frame: 24 hours ]
4. Subarachnoid hemorrhage [ Time Frame: 24 hours ]
5. Hemicraniectomy during index hospitalization [ Time Frame: day 5-7 after randomization/at discharge (whichever is later) ]
6. Length of hospital stay [ Time Frame: day 5-7 after randomization/at discharge (whichever is later) ]

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 85 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Adults (18-85 years) with the final diagnosis of an acute ischemic stroke
2. NIH Stroke Scale Score (NIHSS) ≥ 6
3. Last known well to groin puncture or medical management between 0 to 24 hours
4. Pre-stroke modified Rankin Scale score (mRS) of 0-1
5. Eligible for thrombectomy or medical management
6. Signed Informed Consent obtained
7. Subject willing to comply with the protocol follow-up requirements
8. Anticipated life expectancy of at least 3 months

Specific Neuroimaging Inclusion Criteria:

1. Proven large vessel occlusion in ICA or MCA-M1 occlusion (carotid occlusions can be cervical or intracranial, with or without tandem MCA lesions) determined by MRA or CTA

2. Large infarct-core lesion on at least one of the following:

   • 2.1. Non-Contrast CT (ASPECTS of 3-5),
   • 2.2. CT perfusion (rCBF<30% ≥50cc),
   • 2.3. MRI-DWI (ADC<620 ≥50cc)

Exclusion Criteria:

1. Inability to undergo CT angiography and/or CT perfusion imaging (e.g., renal insufficiency, iodine/contrast allergy)
2. Co-morbid psychiatric or medical illnesses that would confound the neurological assessments
3. Treatment with thrombolytic agent beyond 4.5 hours from last known well

4. Treated with thrombolytic agent 3-4.5 hours after last known well AND any of the following:

   • 1) age >80,
   • 2) current anticoagulant use,
   • 3) history of diabetes AND prior stroke,
   • 4) NIHSS >25,
   • 5) ischemic involvement of > 1/3 MCA territory
5. Current participation in another investigational drug or device study.

Neuroimaging Exclusion Criteria

1. Patients who have both ASPECTS of 6-10 on non-contrast CT AND core volume <50 cc on perfusion imaging
2. Patients with very large core on non-contrast CT i.e. ASPECTS ≤ 2
3. Evidence of intracranial tumor (except small meningioma), acute intracranial hemorrhage, neoplasm, or arteriovenous malformation
4. A significant mass effect with midline shift
5. Evidence of internal carotid artery dissection that is flow limiting or aortic dissection
6. Intracranial stent implanted in the same vascular territory that precludes the safe deployment/removal of the neurothrombectomy device
7. Acute symptomatic arterial occlusions in more than one vascular territory confirmed on CTA/MRA (e.g., bilateral MCA occlusions, or an MCA and a basilar artery occlusion).
8. Signs of established infarct and large area of cerebral edema on non-contrast CT

Contacts and Locations

Locations

United States, California

Kaiser Permanente

Los Angeles, California, United States, 90027

United States, Florida

Baptist Health

Jacksonville, Florida, United States, 32207

United States, Illinois

Rush University Medical Center

Chicago, Illinois, United States, 60612

United States, Indiana

Ascension St. Vincent Hospital

Indianapolis, Indiana, United States, 46260

United States, Iowa

University of Iowa Hospitals and Clinics

Iowa City, Iowa, United States, 52242

United States, Kansas

University of Kansas Medical Center

Kansas City, Kansas, United States, 66160

United States, Michigan

Spectrum Health Hospital

Grand Rapids, Michigan, United States, 49503

United States, New York

Westchester Medical Center

Valhalla, New York, United States, 10595

United States, Ohio

University Hospitals Cleveland Medical Center

Cleveland, Ohio, United States, 44106

Cleveland Clinic Foundation

Cleveland, Ohio, United States, 44195

Riverside Methodist Hospital - OhioHealth

Columbus, Ohio, United States, 43214

United States, Pennsylvania

Abington Jefferson Health

Abington, Pennsylvania, United States, 19001

The Hospital of the University of Pennsylvania

Philadelphia, Pennsylvania, United States, 19104

Thomas Jefferson University Hospital

Philadelphia, Pennsylvania, United States, 19107

United States, Tennessee

Semmes Murphey Clinic - University of Tennessee Health Science Center

Memphis, Tennessee, United States, 38163

United States, Texas

Dell Seton Medical Center at the University of Texas at Austin

Austin, Texas, United States, 78712

Valley Baptist Medical Center

Harlingen, Texas, United States, 78550

The University of Texas Health Science Center at Houston

Houston, Texas, United States, 77030

United States, Wisconsin

Ascension Wisconsin

Milwaukee, Wisconsin, United States, 53215

Australia, New South Wales

Liverpool Hospital - South Western Sydney Clinical School

Liverpool, New South Wales, Australia

Australia, South Australia

The Royal Adelaide Hospital (RAH)

Adelaide, South Australia, Australia

Australia, Victoria

Royal Melbourne Hospital

Melbourne, Victoria, Australia

Canada, Alberta

University of Alberta

Edmonton, Alberta, Canada, T6G 2B7

Canada, Ontario

University Health Network - Toronto Western Hospital

Toronto, Ontario, Canada

New Zealand

Christchurch Hospital

Christchurch, Canterbury, New Zealand

Spain

Hospital Universitario Germans Trias i Pujol

Badalona, Spain

Hospital Clínic i Provincial de Barcelona

Barcelona, Spain

Hospital Universitari de Bellvitge

Barcelona, Spain

Hospital Universitari Vall d'Hebron

Barcelona, Spain

Hospital Clínico Universitario de Valladolid

Valladolid, Spain

Switzerland

Universität Basel

Basel, Switzerland

Sponsors and Collaborators

University Hospitals Cleveland Medical Center

Stryker Neurovascular

The University of Texas Health Science Center, Houston

Investigators

• Principal Investigator: Amrou Sarraj, MD; Case Western Reserve University - University Hospitals Cleveland Medical Center
• Principal Investigator: (Australia and Oceania) Bruce CV Campbell, MBBS PhD; Melbourne Health
• Principal Investigator: (Europe) Marc Ribo, MD; Vall d'Hebron University Hospital, Barcelona

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Sarraj A, Campbell BCV, Christensen S, Sitton CW, Khanpara S, Riascos RF, Pujara D, Shaker F, Sharma G, Lansberg MG, Albers GW; SELECT Investigators. Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well. Neurology. 2022 May 24;98(21):e2084-e2096. doi: 10.1212/WNL.0000000000200269. Epub 2022 Apr 21.

Sarraj A, Hassan AE, Abraham M, Ribo M, Blackburn S, Chen M, Hussain MS, Pereira VM, Ortega-Gutierrez S, Sitton C, Lavori PW, Cai C, Rahbar M, Pujara D, Shaker F, Lansberg MG, Campbell B, Grotta JC, Albers GW; SELECT2 Investigators. A randomized controlled trial to optimize patient's selection for endovascular treatment in acute ischemic stroke (SELECT2): Study protocol. Int J Stroke. 2022 Jul;17(6):689-693. doi: 10.1177/17474930211035032. Epub 2021 Dec 15.

• Responsible Party: Amrou Sarraj, Professor, University Hospitals Cleveland Medical Center
• ClinicalTrials.gov Identifier: NCT03876457
• Other Study ID Numbers: G180275, Pro00056862
• First Posted: March 15, 2019
• Last Update Posted: December 12, 2022
• Last Verified: December 2022

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: Yes

Keywords provided by Amrou Sarraj, University Hospitals Cleveland Medical Center:

Ischemic stroke; Large vessel occlusion; Endovascular thrombectomy

Additional relevant MeSH terms:

Stroke; Ischemic Stroke; Cerebral Infarction; Ischemia; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Pathologic Processes; Brain Infarction; Brain Ischemia; Infarction; Necrosis