Methylprednisolone as Adjunct to Endovascular Thrombectomy for Large-Vessel Occlusion Stroke

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Methylprednisolone as Adjunct to Endovascular Thrombectomy for Large-Vessel Occlusion Stroke

The MARVEL Randomized Clinical Trial

MARVEL Trial Authors for the MARVEL Investigators

Article Information

JAMA. Published online February 8, 2024. doi:10.1001/jama.2024.0626

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• Editorial
  Adjunctive Steroids as Stroke Reperfusion Strategy
  James E. Siegler, MD; Shyam Prabhakaran, MD, MS
  JAMA

Key Points

Question  Among patients with large-vessel occlusion acute ischemic stroke, does adjunctive intravenous methylprednisolone added to endovascular thrombectomy improve clinical outcomes?

Findings  In this randomized clinical trial that included 1680 patients, intravenous methylprednisolone, compared with placebo, as adjunct to endovascular thrombectomy resulted in no significant difference in disability severity between groups as measured by the overall distribution of the modified Rankin Scale score at 90 days (adjusted generalized odds ratio for a lower level of disability, 1.10).

Meaning  Adjunctive methylprednisolone therapy added to endovascular treatment for acute ischemic stroke did not significantly improve the degree of overall disability.

Abstract

Importance  It is uncertain whether intravenous methylprednisolone improves outcomes for patients with acute ischemic stroke due to large-vessel occlusion (LVO) undergoing endovascular thrombectomy.

Objective  To assess the efficacy and adverse events of adjunctive intravenous low-dose methylprednisolone to endovascular thrombectomy for acute ischemic stroke secondary to LVO.

Design, Setting, and Participants  This investigator-initiated, randomized, double-blind, placebo-controlled trial was implemented at 82 hospitals in China, enrolling 1680 patients with stroke and proximal intracranial LVO presenting within 24 hours of time last known to be well. Recruitment took place between February 9, 2022, and June 30, 2023, with a final follow-up on September 30, 2023.

Interventions  Eligible patients were randomly assigned to intravenous methylprednisolone (n = 839) at 2 mg/kg/d or placebo (n = 841) for 3 days adjunctive to endovascular thrombectomy.

Main Outcomes and Measures  The primary efficacy outcome was disability level at 90 days as measured by the overall distribution of the modified Rankin Scale scores (range, 0 [no symptoms] to 6 [death]). The primary safety outcomes included mortality at 90 days and the incidence of symptomatic intracranial hemorrhage within 48 hours.

Results  Among 1680 patients randomized (median age, 69 years; 727 female [43.3%]), 1673 (99.6%) completed the trial. The median 90-day modified Rankin Scale score was 3 (IQR, 1-5) in the methylprednisolone group vs 3 (IQR, 1-6) in the placebo group (adjusted generalized odds ratio for a lower level of disability, 1.10 [95% CI, 0.96-1.25]; P = .17). In the methylprednisolone group, there was a lower mortality rate (23.2% vs 28.5%; adjusted risk ratio, 0.84 [95% CI, 0.71-0.98]; P = .03) and a lower rate of symptomatic intracranial hemorrhage (8.6% vs 11.7%; adjusted risk ratio, 0.74 [95% CI, 0.55-0.99]; P = .04) compared with placebo.

Conclusions and Relevance  Among patients with acute ischemic stroke due to LVO undergoing endovascular thrombectomy, adjunctive methylprednisolone added to endovascular thrombectomy did not significantly improve the degree of overall disability.

Trial Registration  ChiCTR.org.cn Identifier: ChiCTR2100051729

 

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