🩺 THIS WEEK IN EM
Large Core Stroke? Thrombectomy Is Still the Answer. SELECT-2 Made It Official.
For years, a large ischemic core on initial imaging was treated like a thrombectomy stop sign. The assumption was simple: too much tissue already lost, too much hemorrhage risk, too little to gain.
SELECT-2 did a lot to kill that reflex.
The trial randomized 352 patients with large vessel occlusion and a large ischemic core — defined by ASPECTS 3-5 or infarct volume ≥50 mL — to thrombectomy versus medical management. Functional outcomes were clearly better with thrombectomy. At 90 days, functional independence was achieved in 20% of the thrombectomy group versus 7% of the medical group. Ninety-day mortality was 38% with thrombectomy versus 41.5% with medical management. Symptomatic intracranial hemorrhage rates were similar.
ANGEL-ASPECT reached a similar conclusion in a different population, which makes the overall signal much harder to dismiss. The practical implication for EM is that “large core” is no longer a good reason to quietly take thrombectomy off the table. The decision still belongs with a stroke/interventional team, but your job is to activate the system, not pre-exclude the patient.
Bottom line: Large-core stroke is no longer an automatic thrombectomy exclusion. If there is a large vessel occlusion, make the call.
Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med. 2023;388(14):1259-1271.
INTERACT3: ICH Care Works Better as a Bundle Than as a Slogan.
Intracerebral hemorrhage management has suffered from years of people trying to turn a complex disease into a one-liner about blood pressure. INTERACT3 was more useful than that.
Using a stepped-wedge cluster-randomized design across 144 hospitals in 10 countries, the trial implemented a multicomponent care bundle for spontaneous ICH: early blood pressure reduction, glucose control, fever prevention, and rapid reversal of anticoagulation when appropriate. The bundle was associated with better 6-month functional outcomes than usual care.
That does not mean one number fixed ICH. It means organized early care matters. The temptation is always to reduce this trial to “slam every SBP below 140 immediately and call it a day.” That misses the point. The intervention worked as a bundle, not as a bumper sticker.
So the bedside takeaway is broader and more useful: lower the blood pressure early, manage glucose, prevent fever, reverse anticoagulation fast, and stop treating ICH like a disease where shrugging counts as a plan.
Bottom line: In acute ICH, protocolized bundle care improves outcomes. Blood pressure matters, but it is not the whole intervention.
INTERACT3 Investigators. Early intensive blood pressure lowering and standardized care in intracerebral haemorrhage (INTERACT3). Lancet. 2023;402(10395):27-40.
ENRICH: Minimally Invasive ICH Surgery Might Actually Matter Now.
For a long time, “ICH surgery doesn’t work” was the lazy summary of a much messier literature. ENRICH is one reason that summary is getting harder to defend.
The trial randomized 300 patients with spontaneous supratentorial ICH — lobar or basal ganglia, volume 30-80 mL — to early minimally invasive parafascicular surgery versus standard medical management. The primary analysis favored surgery, with the clearest signal in lobar hemorrhage. Early mortality also trended lower in the surgery group.
This does not mean every large hemorrhage needs a neurosurgeon sprinting to the OR. Patient selection still matters, hemorrhage location matters, and center capability matters. But the old nihilism around ICH surgery is increasingly out of date, especially for selected lobar bleeds at places that can actually do this well.
For the ED, the implication is straightforward: control blood pressure, reverse coagulopathy, prevent secondary injury, and involve neurosurgery early when the anatomy and center capability make intervention realistic.
Bottom line: Minimally invasive surgery is now a real consideration for selected ICH patients, especially lobar hemorrhages. Call neurosurgery early.
Pradilla G, Ratcliff JJ, Hall A, et al. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med. 2024;390(14):1277-1289.
📚 STILL CHANGING PRACTICE
If you haven’t internalized this yet, now’s the time.
DAWN: The Trial That Blew Up the Old Stroke Clock.
Before DAWN, thrombectomy mostly lived inside a 6-hour window. If a patient woke up with symptoms or showed up late, they were often functionally excluded.
DAWN changed that.
The trial randomized 206 patients with ICA or proximal MCA occlusion presenting 6-24 hours from last known well, selected by clinical-imaging mismatch. Thrombectomy dramatically improved outcomes: 90-day functional independence was 49% with thrombectomy versus 13% with medical therapy. The trial stopped early because the benefit signal was overwhelming.
The practical takeaway is that time still matters, but imaging matters more than we used to think. Wake-up strokes and late presenters are not automatically out. If the imaging shows salvageable brain, they may still be candidates.
Bottom line: Do not exclude late-presenting or wake-up stroke patients from thrombectomy based on time alone. Imaging selection changed the game.
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018;378(1):11-21.
Next Week 🔭
• Triage, risk stratification, and PE: When is PESI enough and when do you need CTA?
• Ketamine vs. etomidate for RSI in critically ill patients: What the newer head-to-head data shows
• Bedside ultrasound in undifferentiated shock: Evidence update on protocols vs. freestyle scanning
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.