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1. Association of Ischemic Core Imaging Biomarkers With Post-Thrombectomy Clinical Outcomes in the MR CLEAN Registry

Author

Miou S. Koopman, Jan W. Hoving, Manon Kappelhof, Olvert A. Berkhemer, Ludo F. M. Beenen, Wim H. van Zwam, Hugo W. A. M. de Jong, Jan Willem Dankbaar, Diederik W. J. Dippel, Jonathan M. Coutinho, Henk A. Marquering, Bart J. Emmer, Charles B. L. M. Majoie, for the MR CLEAN Registry Investigators, Aad van der Lugt, Yvo B. W. E. M. Roos, Robert J. van Oostenbrugge, Jelis Boiten, Jan Albert Vos, Ivo G. H. Jansen, Maxim J. H. L. Mulder, Robert-Jan B. Goldhoorn, Kars C. J. Compagne, Josje Brouwer, Sanne J. den Hartog, Wouter H. Hinsenveld, Bob Roozenbeek, Adriaan C. G. M. van Es, Wouter J. Schonewille, Marieke J. H. Wermer, Marianne A. A. van Walderveen, Julie Staals, Jeannette Hofmeijer, Jasper M. Martens, Geert J. Lycklama à Nijeholt, Sebastiaan F. de Bruijn, Lukas C. van Dijk, H. Bart van der Worp, Rob H. Lo, Ewoud J. van Dijk, Hieronymus D. Boogaarts, J. de Vries, Paul L. M. de Kort, Julia van Tuijl, Jo P. Peluso, Puck Fransen, Jan S. P. van den Berg, Boudewijn A. A. M. van Hasselt, Leo A. M. Aerden, René J. Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P.H. Bokkers, Tobien H. C. M. L. Schreuder, Roel J. J. Heijboer, Koos Keizer, Lonneke S. F. Yo, Heleen M. den Hertog, Emiel J. C. Sturm, Paul J. A. M. Brouwers, Marieke E. S. Sprengers, Sjoerd F. M. Jenniskens, René van den Berg, Albert J. Yoo, Alida A. Postma, Stefan D. Roosendaal, Bas F. W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Reinoud P. H. Bokkers, Marc P. van Proosdij, G. Menno Krietemeijer, Rob Lo, Dick Gerrits, Wouter Dinkelaar, Auke P. A. Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, H. Zwenneke Flach, Hester F. Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D. Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R. Geuskens, Tim van Straaten, Saliha Ergezen, Roger R. M. Harmsma Daan Muijres, Anouk de Jong, Anna M. M. Boers, J. Huguet, P. F. C. Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon L. Tolhuisen, Heitor Alves, Annick J. Weterings, Eleonora L. F. Kirkels, Lieve M. Schupp, Eva J. H. F. Voogd, Sabine Collette, Adrien E. D. Groot, Natalie E. LeCouffe, Praneeta R. Konduri, Haryadi Prasetya, Nerea Arrarte- Terreros, and Lucas A. Ramos

Subjects
CT perfusion (CTP), ischemic core, thrombectomy, stroke, alberta stroke program early CT score (ASPECTS), collaterals, Neurology. Diseases of the nervous system, RC346-429
Abstract

Background: A considerable proportion of acute ischemic stroke patients treated with endovascular thrombectomy (EVT) are dead or severely disabled at 3 months despite successful reperfusion. Ischemic core imaging biomarkers may help to identify patients who are more likely to have a poor outcome after endovascular thrombectomy (EVT) despite successful reperfusion. We studied the association of CT perfusion-(CTP), CT angiography-(CTA), and non-contrast CT-(NCCT) based imaging markers with poor outcome in patients who underwent EVT in daily clinical practice.Methods: We included EVT-treated patients (July 2016–November 2017) with an anterior circulation occlusion from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry with available baseline CTP, CTA, and NCCT. We used multivariable binary and ordinal logistic regression to analyze the association of CTP ischemic core volume, CTA-Collateral Score (CTA-CS), and Alberta Stroke Program Early CT Score (ASPECTS) with poor outcome (modified Rankin Scale score (mRS) 5-6) and likelihood of having a lower score on the mRS at 90 days.Results: In 201 patients, median core volume was 13 (IQR 5-41) mL. Median ASPECTS was 9 (IQR 8-10). Most patients had grade 2 (83/201; 42%) or grade 3 (28/201; 14%) collaterals. CTP ischemic core volume was associated with poor outcome [aOR per 10 mL 1.02 (95%CI 1.01–1.04)] and lower likelihood of having a lower score on the mRS at 90 days [aOR per 10 mL 0.85 (95% CI 0.78–0.93)]. In multivariable analysis, neither CTA-CS nor ASPECTS were significantly associated with poor outcome or the likelihood of having a lower mRS.Conclusion: In our population of patients treated with EVT in daily clinical practice, CTP ischemic core volume is associated with poor outcome and lower likelihood of shift toward better outcome in contrast to either CTA-CS or ASPECTS.

Published
2022
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2. Prehospital transdermal glyceryl trinitrate in patients with presumed acute stroke (MR ASAP)

Author

Sophie A van den Berg, Simone M Uniken Venema, Hendrik Reinink, Jeannette Hofmeijer, Wouter J Schonewille, Irene Miedema, Puck S S Fransen, D Martijn O Pruissen, Theodora W M Raaijmakers, Gert W van Dijk, Frank-Erik de Leeuw, Jorine A van Vliet, Vincent I H Kwa, Henk Kerkhoff, Alex van 't Net, Rene Boomars, Arjen Siegers, Tycho Lok, Klaartje Caminada, Laura M Esteve Cuevas, Marieke C Visser, Casper P Zwetsloot, Jooske M F Boomsma, Mirjam H Schipper, Roeland P J van Eijkelenburg, Olvert A Berkhemer, Daan Nieboer, Hester F Lingsma, Bart J Emmer, Robert J van Oostenbrugge, Aad van der Lugt, Yvo B W E M Roos, Charles B L M Majoie, Diederik W J Dippel, Paul J Nederkoorn, H Bart van der Worp, Ayla van Ahee, Frank Visseren, Patricia Halkes, Ruben van Eijk, Michelle Simons, Wilma Pellikaan, Wilma Van Wijngaarden, Eva Ponjee, Petra Geijtenbeek, Ton Arts, Elles Zock, Wilma Oudshoorn, Frans Steenwinkel, Hamdia Samim, Mark van Zandwijk, Lisette Vrielink, Peter Jan Mulder, Aico Gerritsen, Jim Ijzermans, Marjan Kooijman, Oscar Francissen, Rick van Nuland, Wim van Zwam, Linda Jacobi, Rene van den Berg, Ludo Beenen, Adriaan van Es, Pieter-Jan van Doormaal, Geert Lycklama a Nijeholt, Ido van den Wijngaard, Albert Yoo, Lonneke Yo, Jasper Martens, Bas Hammer, Stefan Roosendaal, Anton Meijer, Menno Krietemeijer, Reinoud Bokkers, Anouk van der Hoorn, Dick Gerrits, Jonathan Coutinho, Ben Jansen, Sanne Manschot, Peter Koudstaal, Koos Keizer, Vicky Chalos, Adriaan Versteeg, Lennard Wolff, Henk van Voorst, Matthijs van der Sluijs, Arnolt-Jan Hoving, Kilian Treurniet, Natalie LeCouffe, Rob van de Graaf, Robert-Jan Goldhoorn, Wouter Hinseveld, Anne Pirson, Lotte Sondag, Manon Kappelhof, Manon Tolhuisen, Josje Brouwer, Wouter van der Steen, Leon Rinkel, Agnetha Bruggeman, Rita Sprengers, Martin Sterrenberg, Sabrina Verheesen, Leontien Heiligers, Yvonne Martens, Naziha El Ghannouti, Miranda Slotboom, MUMC+: MA Neurologie (3), MUMC+: Hersen en Zenuw Centrum (3), Klinische Neurowetenschappen, RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, RS: Carim - B05 Cerebral small vessel disease, Graduate School, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Neurology, Radiology and Nuclear Medicine, ANS - Cellular & Molecular Mechanisms, ACS - Microcirculation, ACS - Pulmonary hypertension & thrombosis, Biomedical Engineering and Physics, ANS - Brain Imaging, ANS - Compulsivity, Impulsivity & Attention, Radiology & Nuclear Medicine, Public Health, Radiology and nuclear medicine, Pediatrics, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Damage and Repair in Cancer Development and Cancer Treatment (DARE), TechMed Centre, and Clinical Neurophysiology

Subjects
Adult, Adolescent, Ischemic Attack, Transient, Nitroglycerin/therapeutic use, Ambulances, Brain Ischemia/drug therapy, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Brain Ischemia, Stroke, Nitroglycerin, Treatment Outcome, Ischemic Attack, Transient, 2023 OA procedure, Humans, Neurology (clinical), Stroke/drug therapy, Cerebral Hemorrhage/drug therapy, Cerebral Hemorrhage, Ischemic Stroke
Abstract

Contains fulltext : 287508.pdf (Publisher’s version ) (Closed access) BACKGROUND: Pooled analyses of previous randomised studies have suggested that very early treatment with glyceryl trinitrate (also known as nitroglycerin) improves functional outcome in patients with acute ischaemic stroke or intracerebral haemorrhage, but this finding was not confirmed in a more recent trial (RIGHT-2). We aimed to assess whether patients with presumed acute stroke benefit from glyceryl tr initrate started within 3 h after symptom onset. METHODS: MR ASAP was a phase 3, randomised, open-label, blinded endpoint trial done at six ambulance services serving 18 hospitals in the Netherlands. Eligible participants (aged ≥18 years) had a probable diagnosis of acute stroke (as assessed by a paramedic), a face-arm-speech-time test score of 2 or 3, systolic blood pressure of at least 140 mm Hg, and could start treatment within 3 h of symptom onset. Participants were randomly assigned (1:1) by ambulance personnel, using a secure web-based electronic application with random block sizes stratified by ambulance service, to receive either transdermal glyceryl trinitrate 5 mg/day for 24 h plus standard care (glyceryl trinitrate group) or to standard care alone (control group) in the prehospital setting. Informed consent was deferred until after arrival at the hospital. The primary outcome was functional outcome assessed with the modified Rankin Scale (mRS) at 90 days. Safety outcomes included death within 7 days, death within 90 days, and serious adverse events. Analyses were based on modified intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. We separately analysed the total population and the target population (ie, patients with intracerebral haemorrhage, ischaemic stroke, or transient ischaemic attack). The target sample size was 1400 patients. The trial is registered as ISRCTN99503308. FINDINGS: On June 24, 2021, the MR ASAP trial was prematurely terminated on the advice of the data and safety monitoring board, with recruitment stopped because of safety concerns in patients with intracerebral haemorrhage. Between April 4, 2018, and Feb 12, 2021, 380 patients were randomly allocated to a study group. 325 provided informed consent or died before consent could be obtained, of whom 170 were assigned to the glyceryl trinitrate group and 155 to the control group. These patients were included in the total population. 201 patients (62%) had ischaemic stroke, 34 (10%) transient ischaemic attack, 56 (17%) intracerebral haemorrhage, and 34 (10%) a stroke-mimicking condition. In the total population (n=325), the median mRS score at 90 days was 2 (IQR 1-4) in both the glyceryl trinitrate and control groups (adjusted common OR 0·97 [95% CI 0·65-1·47]). In the target population (n=291), the 90-day mRS score was 2 (2-4) in the glyceryl trinitrate group and 3 (1-4) in the control group (0·92 [0·59-1·43]). In the total population, there were no differences between the two study groups with respect to death within 90 days (adjusted OR 1·07 [0·53-2·14]) or serious adverse events (unadjusted OR 1·23 [0·76-1·99]). In patients with intracerebral haemorrhage, 12 (34%) of 35 patients allocated to glyceryl trinitrate versus two (10%) of 21 allocated to the control group died within 7 days (adjusted OR 5·91 [0·78-44·81]); death within 90 days occurred in 16 (46%) of 35 in the glyceryl trinitrate group and 11 (55%) of 20 in the control group (adjusted OR 0·87 [0·18-4·17]). INTERPRETATION: We found no sign of benefit of transdermal glyceryl trinitrate started within 3 h of symptom onset in the prehospital setting in patients with presumed acute stroke. The signal of potential early harm of glyceryl trinitrate in patients with intracerebral haemorrhage suggests that glyceryl trinitrate should be avoided in this setting. FUNDING: The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.

Published
2022
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3. Effect of Intravenous Alteplase Treatment on First-Line Stent Retriever Versus Aspiration Alone During Endovascular Treatment

Author

Leon A. Rinkel, Kilian M. Treurniet, Daan Nieboer, Manon Kappelhof, Natalie E. LeCouffe, Agnetha A.E. Bruggeman, Wim H. van Zwam, Geert J. Lycklama à Nijeholt, Elyas Ghariq, Maarten Uyttenboogaart, Diederik W.J. Dippel, Yvo B.W.E.M. Roos, Jonathan M. Coutinho, Charles B.L.M. Majoie, Bart J. Emmer, Bob Roozenbeek, Adriaan van Es, Inger de Ridder, Bart van der Worp, Rob Lo, Koos Keizer, Rob Gons, Lonneke Yo, Jelis Boiten, Ido van den Wijngaard, Jeanette Hofmeijer, Jasper Martens, Wouter Schonewille, Jan Albert Vos, Anil Tuladhar, Floris Schreuder, Jeroen Boogaarts, Sjoerd Jenniskens, Karlijn de Laat, Lukas van Dijk, Heleen den Hertog, Boudewijn van Hasselt, Paul Brouwers, Emiel Sturm, Tomas Bulut, Michel Remmers, Anouk van Norden, Thijs de Jong, Anouk Rozeman, Otto Elgersma, Reinoud Bokkers, Julia van Tuijl, Issam Boukrab, Hans Kortman, Vincent Costalat, Caroline Arquizan, Robin Lemmens, Jelle Demeestere, Philippe Desfontaines, Denis Brisbois, Frédéric Clarençon, Yves Samson, Martin Brown, Phil White, John Gregson, Rick van Nuland, Aad van der Lugt, Linda Jacobi, René van den Berg, Ludo Beenen, Pieter-Jan van Doormaal, Albert Yoo, Bas Hammer, Stefan Roosendaal, Anton Meijer, Menno Krietemeijer, Anouk van der Hoorn, Dick Gerrits, Robert van Oostenbrugge, Ben Jansen, Sanne Manschot, Henk Kerkhof, Peter Koudstaal, Hester Lingsma, Vicky Chalos, Olvert Berkhemer, Adriaan Versteeg, Lennard Wolff, Jiahang Su, Manon Tolhuisen, Henk van Voorst, Hugo ten Cate, Moniek de Maat, Samantha Donse-Donkel, Heleen van Beusekom, Aladdin Taha, Sophie van den Berg, Rob van de Graaf, Robert-Jan Goldhoorn, Wouter Hinsenveld, Anne Pirson, Lotte Sondag, Rik Reinink, Josje Brouwer, Sabine Collette, Wouter van der Steen, Rita Sprengers, Martin Sterrenberg, Naziha El Ghannouti, Sabrina Verheesen, Wilma Pellikaan, Kitty Blauwendraat, Yvonne Drabbe, Joke de Meris, Michelle Simons, Hester Bongenaar, Anja van Loon, Eva Ponjee, Rieke Eilander, Suze Kooij, Marieke de Jong, Esther Santegoets, Suze Roodenburg, Ayla van Ahee, Marinette Moynier, Annemie Devroye, Evelyn Marcis, Ingrid Iezzi, Annie David, Atika Talbi, Leontien Heiligers, Yvonne Martens, Radiology and nuclear medicine, ACS - Atherosclerosis & ischemic syndromes, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Damage and Repair in Cancer Development and Cancer Treatment (DARE), Graduate School, Neurology, Radiology and Nuclear Medicine, ACS - Microcirculation, ANS - Cellular & Molecular Mechanisms, ANS - Compulsivity, Impulsivity & Attention, ANS - Neurovascular Disorders, Biomedical Engineering and Physics, ANS - Brain Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B05 Cerebral small vessel disease, RS: Carim - B06 Imaging, Public Health, Hematology, Radiology & Nuclear Medicine, and Cardiology

Subjects
Advanced and Specialized Nursing, Endovascular Procedures, patients, reperfusion, Brain Ischemia, Stroke, Treatment Outcome, Tissue Plasminogen Activator, Humans, stent, Stents, Neurology (clinical), Cardiology and Cardiovascular Medicine, Ischemic Stroke, Thrombectomy
Abstract

Background: We aimed to assess whether the effect of intravenous alteplase treatment (IVT) before endovascular treatment (EVT) on outcome is modified by first-line technique during EVT in IVT eligible patients. Methods: This was a post hoc analysis from MR CLEAN-NO IV (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands - Intravenous Treatment Followed by Intra-Arterial Treatment Versus Direct Intra-Arterial Treatment for Acute Ischemic Stroke Caused by a Proximal Intracranial Occlusion), a randomized trial of IVT followed by EVT versus EVT alone in patients presenting directly to EVT-capable centers. We included data from all patients who underwent EVT with a thrombectomy attempt. We compared patients treated with stent retriever (with or without aspiration) to aspiration alone as first-line EVT technique and assessed the interaction of first-line EVT technique with IVT treatment. Primary outcome was the 90-day modified Rankin Scale score, analyzed with mixed model ordinal regression for a shift towards better outcome. Secondary outcomes included successful reperfusion (extended Thrombolysis in Cerebral Infarction score 2b–3). Results: Of 473 included patients, 102 (21.6%) were treated with aspiration alone as first-line technique. In the full population, functional outcome was similar for patients treated with stent retriever versus aspiration only (adjusted common odds ratio [acOR]‚ 1.07 [95% CI, 0.69–1.66]). We observed a significant interaction between IVT and first-line EVT technique ( P =0.03). In the aspiration-only group, patients treated with EVT alone had worse functional outcome compared to those treated with IVT and EVT (acOR, 0.44 [95% CI, 0.21–0.90]). In the stent retriever group, functional outcome did not differ between patients treated with or without IVT (acOR, 1.08 [95% CI, 0.74–1.57]). There was no statistically significant interaction for successful reperfusion. Conclusions: In MR CLEAN-NO IV, the treatment effect of IVT was modified by first-line EVT technique. Patients treated with aspiration only as first-line technique had worse clinical outcomes if they did not receive IVT. No such difference was observed in patients treated with stent retrievers. Confirmation by pooling with results from other trials is needed to confirm these findings.

Published
2022
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4. Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice: Results of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry

Author

F. Anne V. Pirson, Nikki Boodt, Josje Brouwer, Agnetha A.E. Bruggeman, Sanne J. den Hartog, Robert-Jan B. Goldhoorn, Lucianne C.M. Langezaal, Julie Staals, Wim H. van Zwam, Christiaan van der Leij, Rutger J.B. Brans, Charles B.L.M. Majoie, Jonathan M. Coutinho, Bart J. Emmer, Diederik W.J. Dippel, Aad van der Lugt, Jan-Albert Vos, Robert J. van Oostenbrugge, Wouter J. Schonewille, Yvo B.W.E.M. Roos, Jelis Boiten, Jan Albert Vos, Ivo G.H. Jansen, Maxim J.H.L. Mulder, Kars C.J. Compagne, Manon Kappelhof, Wouter H. Hinsenveld, Bob Roozenbeek, Marieke J.H. Wermer, Marianne A.A. van Walderveen, Adriaan C.G.M. van Es, Jeannette Hofmeijer, Jasper M. Martens, Geert J. Lycklama à Nijeholt, Sebastiaan F. de Bruijn, Lukas C. van Dijk, H. Bart van der Worp, Rob H. Lo, Ewoud J. van Dijk, Hieronymus D. Boogaarts, J. de Vries, Paul L.M. de Kort, Julia van Tuijl, Jo P. Peluso, Puck Fransen, Jan S.P. van den Berg, Boudewijn A.A.M. van Hasselt, Leo A.M. Aerden, René J. Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P.H. Bokkers, Tobien H.C.M.L. Schreuder, Roel J.J. Heijboer, Koos Keizer, Lonneke S.F. Yo, Heleen M. den Hertog, Emiel J.C. Sturm, Paul J.A.M. Brouwers, Marieke E.S. Sprengers, Sjoerd F.M. Jenniskens, René van den Berg, Albert J. Yoo, Ludo F.M. Beenen, Alida A. Postma, Stefan D. Roosendaal, Bas F.W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Marc P. van Proosdij, G. Menno Krietemeijer, Rob Lo, Dick Gerrits, Wouter Dinkelaar, Auke P.A. Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, Sandra Cornelissen, H. Zwenneke Flach, Hester F. Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D. Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R. Geuskens, Tim van Straaten, Saliha Ergezen, Roger R.M. Harmsma, Daan Muijres, Anouk de Jong, Olvert A. Berkhemer, Anna M.M. Boers, J. Huguet, P.F.C. Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon L. Tolhuisen, Heitor Alves, Annick J. Weterings, Eleonora L.F. Kirkels, Eva J.H.F. Voogd, Lieve M. Schupp, Sabine L. Collette, Adrien E.D. Groot, Natalie E. LeCouffe, Praneeta R. Konduri, Haryadi Prasetya, Nerea Arrarte-Terreros, Lucas A. Ramos, Neurology, Graduate School, Radiology and Nuclear Medicine, ACS - Microcirculation, ANS - Brain Imaging, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Klinische Neurowetenschappen, MUMC+: MA Niet Med Staf Neurologie (9), RS: Carim - B05 Cerebral small vessel disease, MUMC+: MA AIOS Neurologie (9), MUMC+: MA Med Staf Spec Neurologie (9), Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, MUMC+: MA Neurologie (3), Radiology & Nuclear Medicine, Public Health, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Damage and Repair in Cancer Development and Cancer Treatment (DARE), and Radiology and nuclear medicine

Subjects
Male, medicine.medical_specialty, Mechanical Thrombolysis, posterior stroke, Treatment outcome, law.invention, Postoperative Complications, Randomized controlled trial, law, large vessel occlusion, medicine, Humans, Routine clinical practice, Prospective Studies, Endovascular treatment, PREDICTORS, Stroke, Acute ischemic stroke, Aged, Ischemic Stroke, Netherlands, Advanced and Specialized Nursing, OUTCOMES, BASILAR ARTERY-OCCLUSION, business.industry, Endovascular Procedures, Other Research Radboud Institute for Health Sciences [Radboudumc 0], registries, Middle Aged, THROMBECTOMY, medicine.disease, reperfusion, Clinical Practice, Tissue Plasminogen Activator, Emergency medicine, treatment outcome, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Intracranial Hemorrhages, Large vessel occlusion
Abstract

Background and Purpose: The benefit of endovascular treatment (EVT) for posterior circulation stroke (PCS) remains uncertain, and little is known on treatment outcomes in clinical practice. This study evaluates outcomes of a large PCS cohort treated with EVT in clinical practice. Simultaneous to this observational study, several intervention centers participated in the BASICS trial (Basilar Artery International Cooperation Study), which tested the efficacy of EVT for basilar artery occlusion in a randomized setting. We additionally compared characteristics and outcomes of patients treated outside BASICS in trial centers to those from nontrial centers. Methods: We included patients with PCS from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry: a prospective, multicenter, observational study of patients who underwent EVT in the Netherlands between 2014 and 2018. Primary outcome was a score of 0 to 3 on the modified Rankin Scale at 90 days. Secondary outcomes included reperfusion status and symptomatic intracranial hemorrhage. For outcome comparison between patients treated in trial versus nontrial centers, we used ordinal logistic regression analysis. Results: We included 264 patients of whom 135 (51%) had received intravenous thrombolysis. The basilar artery was most often involved (77%). Favorable outcome (modified Rankin Scale score 0–3) was observed in 115/252 (46%) patients, and 109/252 (43%) patients died. Successful reperfusion was achieved in 178/238 (75%), and symptomatic intracranial hemorrhage occurred in 9/264 (3%). The 154 nontrial patients receiving EVT in BASICS trial centers had similar characteristics and outcomes as the 110 patients treated in nontrial centers (modified Rankin Scale adjusted cOR: 0.77 [95% CI, 0.5–1.2]). Conclusions: Our study shows that high rates of favorable clinical outcome and successful reperfusion can be achieved with EVT for PCS, despite high mortality. Characteristics and outcomes of patients treated in trial versus nontrial centers were similar indicating that our cohort is representative of clinical practice in the Netherlands. Randomized studies using modern treatment approaches are needed for further insight in the benefit of EVT for PCS.

Published
2022
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5. Prognostic Value of Thrombus Volume and Interaction With First-Line Endovascular Treatment Device Choice

Author

Henk van Voorst, Agnetha A.E. Bruggeman, Jurr Andriessen, Jan W. Hoving, Praneeta R. Konduri, Wenjin Yang, Manon Kappelhof, Nerea Arrarte Terreros, Yvo B.W.E.M. Roos, Wim H. van Zwam, Aad van der Lugt, Anouk van der Hoorn, Jelis Boiten, Stefan Roosendaal, Sjoerd Jenniskens, Matthan W.A. Caan, Henk A. Marquering, Bart J. Emmer, Charles B.L.M. Majoie, Diederik W.J. Dippel, Robert J. van Oostenbrugge, Jan Albert Vos, Ivo G.H. Jansen, Maxim J.H.L. Mulder, Robert- Jan B. Goldhoorn, Kars C.J. Compagne, Josje Brouwer, Sanne J. den Hartog, Wouter H. Hinsenveld, Bob Roozenbeek, Adriaan C.G.M. van Es, Jonathan M. Coutinho, Wouter J. Schonewille, Marieke J.H. Wermer, Marianne A.A. van Walderveen, Julie Staals, Jeannette Hofmeijer, Jasper M. Martens, Geert J. Lycklama à Nijeholt, Sebastiaan F. de Bruijn, Lukas C. van Dijk, H. Bart van der Worp, Rob H. Lo, Ewoud J. van Dijk, Hieronymus D. Boogaarts, J. de Vries, Paul L.M. de Kort, Julia van Tuijl, Jo P. Peluso, Puck Fransen, Jan S.P. van den Berg, Boudewijn A.A.M. van Hasselt, Leo A.M. Aerden, René J. Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P.H. Bokkers, Tobien H.C.M.L. Schreuder, Roel J.J. Heijboer, Koos Keizer, Lonneke S.F. Yo, Heleen M. den Hertog, Emiel J.C. Sturm, Paul J.A.M. Brouwers, Marieke E.S. Sprengers, René van den Berg, Albert J. Yoo, Ludo F.M. Beenen, Alida A. Postma, Bas F.W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Marc P. van Proosdij, G. Menno Krietemeijer, Rob Lo, Dick Gerrits, Wouter Dinkelaar, Auke P.A. Appelman, Bas Hammer, Sjoert Pegge, Saman Vinke, H. Zwenneke Flach, Hester F. Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D. Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R. Geuskens, Tim van Straaten, Saliha Ergezen, Roger R.M. Harmsma, Daan Muijres, Anouk de Jong, Olvert A. Berkhemer, Anna M.M. Boers, J. Huguet, P.F.C. Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon L. Tolhuisen, Heitor Alves, Annick J. Weterings, Eleonora L.F. Kirkels, Eva J.H.F. Voogd, Lieve M. Schupp, Sabine Collette, Adrien E.D. Groot, Natalie E. LeCouffe, Haryadi Prasetya, Lucas A. Ramos, Radiology and Nuclear Medicine, Biomedical Engineering and Physics, ANS - Brain Imaging, APH - Methodology, APH - Aging & Later Life, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, ACS - Microcirculation, Pediatrics, Radiology and nuclear medicine, Damage and Repair in Cancer Development and Cancer Treatment (DARE), and ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE)

Subjects
IMPACT, RECANALIZATION, GUIDELINES, functional status, All institutes and research themes of the Radboud University Medical Center, Brain Ischemia/diagnostic imaging, LENGTH, ischemic stroke, Humans, Ischemic Stroke/complications, thrombosis, Retrospective Studies, Advanced and Specialized Nursing, Other Research Radboud Institute for Health Sciences [Radboudumc 0], THROMBECTOMY, Endovascular Procedures/methods, Treatment Outcome, Thrombosis/diagnostic imaging, Thrombectomy/methods, stents, HEART, Neurology (clinical), prognosis, Cardiology and Cardiovascular Medicine, STROKE, Stroke/diagnostic imaging
Abstract

Background: A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment. Methods: In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes. Results: Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71–0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16–0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24–0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50–0.89]; P =0.005; adjusted cOR, 0.74 [95% CI, 0.55–1.0]; P =0.04). Conclusions: In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.

Published
2023
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6. Etiology of Large Vessel Occlusion Posterior Circulation Stroke: Results of the MR CLEAN Registry

Author

F.A.V. (Anne) Pirson, Nikki Boodt, Josje Brouwer, Agnetha A.E. Bruggeman, Wouter H. Hinsenveld, Julie Staals, Wim H. van Zwam, Christiaan van der Leij, Rutger J.B. Brans, Charles B.L.M. Majoie, Diederik W.J. Dippel, Aad van der Lugt, Wouter J. Schonewille, Robert J. van Oostenbrugge, Yvo B.W.E.M. Roos, Jelis Boiten, Jan Albert Vos, Ivo G.H. Jansen, Maxim J.H.L. Mulder, Robert- Jan B. Goldhoorn, Kars C.J. Compagne, Manon Kappelhof, Sanne J. den Hartog, Bob Roozenbeek, Bart J. Emmer, Jonathan M. Coutinho, Marieke J.H. Wermer, Marianne A.A. van Walderveen, Adriaan C.G.M. van Es, Jeannette Hofmeijer, Jasper M. Martens, Geert J. Lycklama à Nijeholt, Sebastiaan F. de Bruijn, Lukas C. van Dijk, H. Bart van der Worp, Rob H. Lo, Ewoud J. van Dijk, Hieronymus D. Boogaarts, J. de Vries, Paul L.M. de Kort, Julia van Tuijl, Jo P. Peluso, Puck Fransen, Jan S.P. van den Berg, Boudewijn A.A.M. van Hasselt, Leo A.M. Aerden, René J. Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P.H. Bokkers, Tobien H.C.M.L. Schreuder, Roel J.J. Heijboer, Koos Keizer, Lonneke S.F. Yo, Heleen M. den Hertog, Emiel J.C. Sturm, Paul J.A.M. Brouwers, Marieke E.S. Sprengers, Sjoerd F.M. Jenniskens, René van den Berg, Albert J. Yoo, Ludo F.M. Beenen, Alida A. Postma, Stefan D. Roosendaal, Bas F.W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Marc P. van Proosdij, G. Menno Krietemeijer, Rob Lo, Dick Gerrits, Wouter Dinkelaar, Auke P.A. Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, Sandra Cornelissen, Rutger Brans, H. Zwenneke Flach, Hester F. Lingsma, Naziha el Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D. Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R. Geuskens, Tim van Straaten, Saliha Ergezen, Roger R.M. Harmsma, Daan Muijres, Anouk de Jong, Olvert A. Berkhemer, Anna M.M. Boers, J. Huguet, P.F.C. Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon L. Tolhuisen, Heitor Alves, Annick J. Weterings, Eleonora L.F. Kirkels, Eva J.H.F. Voogd, Lieve M. Schupp, Sabine L. Collette, Adrien E.D. Groot, Natalie E. LeCouffe, Praneeta R. Konduri, Haryadi Prasetya, Nerea Arrarte-Terreros, Lucas A. Ramos, Anne F.A.V. Pirson, Graduate School, Biomedical Engineering and Physics, ACS - Atherosclerosis & ischemic syndromes, ACS - Microcirculation, ANS - Brain Imaging, ANS - Neurovascular Disorders, Neurology, Radiology & Nuclear Medicine, Public Health, Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, MUMC+: MA Niet Med Staf Neurologie (9), MUMC+: MA Med Staf Spec Neurologie (9), Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, MUMC+: MA Neurologie (3), MUMC+: Hersen en Zenuw Centrum (3), ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Damage and Repair in Cancer Development and Cancer Treatment (DARE), and Radiology and nuclear medicine

Subjects
DIAGNOSIS, EMBOLIC STROKES, UNDETERMINED SOURCE, embolic stroke, ischemic stroke, Humans, Prospective Studies, Registries, Advanced and Specialized Nursing, OUTCOMES, BASILAR ARTERY-OCCLUSION, CLINICAL-FEATURES, Endovascular Procedures, Other Research Radboud Institute for Health Sciences [Radboudumc 0], reperfusion, Stroke, Treatment Outcome, ISCHEMIC-STROKE, thrombectomy, ENDOVASCULAR TREATMENT, RISK-FACTORS, Neurology (clinical), atherosclerosis, Cardiology and Cardiovascular Medicine, SUBTYPE, Rare cancers Radboud Institute for Health Sciences [Radboudumc 9]
Abstract

Background: In patients with large vessel occlusion stroke of the anterior circulation, underlying cause is a determinant of outcome. Whether this is the case for posterior circulation large vessel occlusion stroke has yet to be determined. We aimed to report on cause in patients with posterior circulation stroke treated with endovascular thrombectomy and to analyze the association with functional outcome. Methods: We used data of patients with posterior circulation stroke included in the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, a prospective multicenter observational study, between 2014 and 2018. Stroke cause was categorized into large artery atherosclerosis (LAA), cardioembolism, arterial dissection, embolic stroke of undetermined source (ESUS), other determined cause, or undetermined cause. For primary analysis on the association between cause and outcome, we used multivariable ordinal logistic regression analysis to estimate the adjusted common odds ratio for a shift towards a better functional outcome on the modified Rankin Scale at 90 days with LAA as a reference group. Secondary outcomes included favorable functional outcome (modified Rankin Scale score 0–3), National Institutes of Health Stroke Scale score at 24 to 48 hours, reperfusion on digital subtraction angiography, and stroke progression. Results: Of 264 patients with posterior circulation stroke, 84 (32%) had LAA, 48 (18%) cardioembolism, 31 (12%) dissection, and 14 (5%) ESUS. Patients with a dissection were younger (48 [interquartile range, 43–60] years) and had a lower National Institutes of Health Stroke Scale at baseline (12 [interquartile range, 6–31]) than patients with other cause. Functional outcome was better for patients with cardioembolism and ESUS compared to LAA (modified Rankin Scale adjusted common odds ratio, 2.4 [95% CI, 1.1–5.2], respectively adjusted common odds ratio, 3.1 [95% CI, 1.0–9.3]). Patients with a dissection had a lower chance of successful reperfusion compared with LAA (adjusted odds ratio, 0.20 [95% CI, 0.06–0.70]). Conclusions: Unlike the anterior circulation, most frequent cause in our posterior large vessel occlusion stroke cohort is LAA followed by cardioembolism, dissection, and ESUS. Patients with cardioembolism and ESUS have a better prognosis for functional outcome after endovascular thrombectomy than patients with LAA.

Published
2022
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7. Hospital Variation in Time to Endovascular Treatment for Ischemic Stroke: What Is the Optimal Target for Improvement?

Author

Sanne J. den Hartog, Hester F. Lingsma, Pieter‐Jan van Doormaal, Jeannette Hofmeijer, Lonneke S. F. Yo, Charles B. L. M. Majoie, Diederik W. J. Dippel, Aad van der Lugt, Bob Roozenbeek, Yvo B. W. E. M. Roos, Robert J. van Oostenbrugge, Wim H. van Zwam, Jelis Boiten, Jan Albert Vos, Ivo G. H. Jansen, Maxim J. H. L. Mulder, Robert‐ Jan B. Goldhoorn, Kars C. J. Compagne, Manon Kappelhof, Josje Brouwer, Wouter H. Hinsenveld, Adriaan C. G. M. van Es, Bart J. Emmer, Jonathan M. Coutinho, Wouter J. Schonewille, Marieke J. H. Wermer, Marianne A. A. van Walderveen, Julie Staals, Jasper M. Martens, Geert J. Lycklama à Nijeholt, Sebastiaan F. de Bruijn, Lukas C. van Dijk, H. Bart van der Worp, Rob H. Lo, Ewoud J. van Dijk, Hieronymus D. Boogaarts, J. de Vries, Paul L. M. de Kort, Julia van Tuijl, Jo P. Peluso, Puck Fransen, Jan S. P. van den Berg, Boudewijn A. A. M. van Hasselt, Leo A. M. Aerden, René J. Dallinga, Maarten Uyttenboogaart, Omid Eschgi, Reinoud P. H. Bokkers, Tobien H. C. M. L. Schreuder, Roel J. J. Heijboer, Koos Keizer, Heleen M. den Hertog, Emiel J. C. Sturm, Paul J. A. M. Brouwers, Marieke E. S. Sprengers, Sjoerd F. M. Jenniskens, René van den Berg, Albert J. Yoo, Ludo F. M. Beenen, Alida A. Postma, Stefan D. Roosendaal, Bas F. W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Anton Meijer, Elyas Ghariq, Marc P. van Proosdij, G. Menno Krietemeijer, Dick Gerrits, Wouter Dinkelaar, Auke P. A. Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, H Zwenneke Flach, Naziha el Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Gert Messchendorp, Nynke Nicolaij, Hester Bongenaar, Karin Bodde, Sandra Kleijn, Jasmijn Lodico, Hanneke Droste, Maureen Wollaert, Sabrina Verheesen, D. Jeurrissen, Erna Bos, Yvonne Drabbe, Michelle Sandiman, Nicoline Aaldering, Berber Zweedijk, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R. Geuskens, Tim van Straaten, Saliha Ergezen, Roger R. M. Harmsma, Daan Muijres, Anouk de Jong, Olvert A. Berkhemer, Anna M. M. Boers, J. Huguet, P. F. C. Groot, Marieke A. Mens, Katinka R. van Kranendonk, Kilian M. Treurniet, Manon L. Tolhuisen, Heitor Alves, Annick J. Weterings, Eleonora L. F. Kirkels, Eva J. H. F. Voogd, Lieve M. Schupp, Sabine L. Collette, Adrien E. D. Groot, Natalie E. LeCouffe, Praneeta R. Konduri, Haryadi Prasetya, Nerea Arrarte‐Terreros, Lucas A. Ramos, Radiology and Nuclear Medicine, ANS - Neurovascular Disorders, ACS - Microcirculation, ACS - Atherosclerosis & ischemic syndromes, Radiology & Nuclear Medicine, Neurology, Public Health, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), and Damage and Repair in Cancer Development and Cancer Treatment (DARE)

Subjects
Other Research Radboud Institute for Health Sciences [Radboudumc 0], Endovascular Procedures, Hospitals, Stroke, Brain ischemia, Treatment Outcome, surgical procedures, operative, RC666-701, Reperfusion, Humans, Diseases of the circulatory (Cardiovascular) system, cardiovascular diseases, Quality improvement, Cardiology and Cardiovascular Medicine, Ischemic Stroke, Thrombectomy
Abstract

Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between‐hospital and within‐hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door‐to‐reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door‐to‐reperfusion time was subdivided into time intervals, separately for direct patients (door‐to‐computed tomography, computed tomography‐to‐computed tomography angiography [CTA], CTA‐to‐groin, and groin‐to‐reperfusion times) and for transferred patients (door‐to‐groin and groin‐to‐reperfusion times). We used linear mixed models to distinguish the variation in door‐to‐reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between‐hospital variation in door‐to‐reperfusion time was 9%, and the within‐hospital variation was 91%. The contribution of case‐mix variables on the variation in door‐to‐reperfusion time was marginal (2%–7%). Of the between‐hospital variation, CTA‐to‐groin time explained 83%, whereas groin‐to‐reperfusion time explained 15%. Within‐hospital variation was mostly explained by CTA‐to‐groin time (33%) and groin‐to‐reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door‐to‐reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between‐hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA‐to‐groin time and groin‐to‐reperfusion time.

Published
2022

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