A recent clinical trial published in JAMA has revealed that endovascular thrombectomy does not significantly improve outcomes for patients with large core strokes when compared to standard stroke care alone. The Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA) trial, a multicenter study, challenges previous assumptions about the broad applicability of thrombectomy in stroke patients.
The TESLA trial enrolled 300 patients presenting within 24 hours of stroke onset with large core infarcts, as identified by noncontrast CT scans. Participants were randomized to either endovascular thrombectomy plus standard care or standard care alone. The primary outcome was the difference in patient outcomes after 90 days.
Key Findings of the TESLA Trial
The study found no statistically significant improvement in patient outcomes in the thrombectomy group compared to the control group after the 90-day follow-up period. Specifically, mortality rates were similar between the two groups (35.3% in the thrombectomy group versus 33.3% in the control group). Furthermore, symptomatic intracranial hemorrhage within 24 hours occurred in 4% of patients in the intervention group and 1.3% in the control group.
According to Sameer A. Ansari, MD, Ph.D., a co-author of the study and professor at Northwestern University, earlier trials demonstrated the benefit of thrombectomy by pre-selecting patients most likely to benefit. The TESLA trial was initiated to address concerns about potentially over-selecting patients and denying treatment to those with medium- or large-core infarcts who might still benefit.
Implications for Stroke Treatment
Despite the negative findings, the TESLA trial provides valuable insights for refining stroke treatment protocols. "More importantly, due to TESLA's broad inclusion criteria, we realized there is likely a limit to the amount of stroke burden that a patient can suffer and still benefit from stroke thrombectomy," Ansari noted.
The study also suggests that non-contrast CT imaging may be sufficient for including or excluding patients for thrombectomy, potentially reducing costs and time in the triage process. Future research will focus on refining CT imaging selection criteria and identifying patient populations that will benefit most from thrombectomy.
Future Directions
Ongoing trials and studies are exploring the expansion of thrombectomy indications, such as in patients with more distal or smaller vessel occlusions or those presenting in later time windows with salvageable tissue profiles. These efforts aim to further define the optimal use of thrombectomy in stroke management.
