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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. Peripheral Artery Disease in Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy; Results From the MR CLEAN Registry

Author

France A. V. Pirson, Wouter H. Hinsenveld, Julie Staals, Inger R. de Ridder, Wim H. van Zwam, Tobien H. C. M. L. Schreuder, Yvo B. W. E. M. Roos, Charles B. L. M. Majoie, H. Bart van der Worp, Maarten Uyttenboogaart, Geert J. Lycklama à Nijeholt, Wouter J. Schonewille, and Robert J. van Oostenbrugge

Subjects
peripheral artery disease, acute ischemic stroke, ischemic preconditioning, endovascular treatment, functional outcome, Neurology. Diseases of the nervous system, RC346-429
Abstract

Background and Purpose: Though peripheral artery disease (PAD) is a well-known risk factor for ischemic events, better outcomes have been described in acute ischemic stroke patients with co-existing PAD. This paradoxical association has been attributed to remote ischemic preconditioning (RIPC) and might be related to better collateral blood flow. The aim of this study is to compare outcomes after endovascular thrombectomy (EVT) in acute stroke patients with and without PAD and to assess the relation between PAD and collateral grades.Methods: We analyzed acute ischemic stroke patients treated with EVT for an anterior circulation large artery occlusion, included in the Dutch, prospective, multicenter MR CLEAN Registry between March 2014 and November 2017. Collaterals were scored on CT angiography, using a 4-point collateral score. We used logistic regression analysis to estimate the association of PAD with collateral grades and functional outcome, assessed with the modified Rankin Scale (mRS) at 90 days. Safety outcomes included mortality at 90 days, symptomatic intracranial hemorrhage, and stroke progression.Results: We included 2,765 patients for analysis, of whom 254 (9.2%) had PAD. After adjustment for potential confounders, multivariable regression analysis showed no association of PAD with functional outcome [mRS cOR 0.90 (95% CI, 0.7–1.2)], collateral grades (cOR 0.85, 95% CI 0.7–1.1), or safety outcomes.Conclusion: In the absence of an association between the presence of PAD and collateral scores or outcomes after EVT, it may be questioned whether PAD leads to RIPC in patients with acute ischemic stroke due to large vessel occlusion.

Published
2020
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3. Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care

Author

Marzyeh Amini, Frank Eijkenaar, Hester F. Lingsma, Sanne J. den Hartog, Susanne G. H. Olthuis, Jasper Martens, Bart van der Worp, Wim van Zwam, Anouk van der Hoorn, Stefan D. Roosendaal, Bob Roozenbeek, Diederik Dippel, Nikki van Leeuwen, Diederik W. J. Dippel, Aad van der Lugt, Charles B. L. M. Majoie, Yvo B. W. E. M. Roos, Robert J. van Oostenbrugge, Wim H. van Zwam, Jelis Boiten, Jan Albert Vos, Josje Brouwer, Wouter H. Hinsenveld, Manon Kappelhof, Kars C. J. Compagne, Robert‐Jan B. Goldhoorn, Maxim J. H. L. Mulder, Ivo G. H. Jansen, 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, 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 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 Brouwers, Marieke E. S. Sprengers, Sjoerd F. M. Jenniskens, 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, Jo P. Peluso, Rob Lo, Wouter Dinkelaar, Auke P. A. Appelman, Bas Hammer, Sjoert Pegge, Saman Vinke, H. Zwenneke Flach, Naziha el Ghannouti, Martin Sterrenberg, Corina Puppels, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, Cathelijn van Rijswijk, 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, Mostafa Khalilzada, 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, Praneeta R. Konduri, Haryadi Prasetya, Nerea Arrarte‐Terreros, Lucas A. Ramos, Public Health, Health Systems and Insurance (HSI), Neurology, Radiology & Nuclear Medicine, Pediatrics, Radiology and nuclear medicine, 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
acute ischemic stroke, expanded thrombolysis in cerebral infarction, THROMBECTOMY, PERFORMANCE, case-mix, National Institutes of Health Stroke Scale, hospitals' patient volume, early outcome, quality of care, IMPUTATION, HEALTH, RATES, Cardiology and Cardiovascular Medicine, hospitals’ patient volume, SCALE
Abstract

Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between‐hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between‐hospital variation in outcomes was assessed using the variance of random hospital effects (tau 2 ). In addition, we estimated the correlation between hospitals' EVT‐patient volume and (case‐mix–adjusted) outcomes. Both early outcomes and case‐mix characteristics varied significantly across hospitals. Between‐hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case‐mix adjustment (tau 2 =0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case‐mix adjustment led to a decrease in variation between hospitals (tau 2 decreases from 0.19 to 0.17). Hospitals' EVT‐patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores ( r =0.48) and weakly with lower NIHSS score at 24 to 48 hours ( r =0.15). Conclusions Between‐hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case‐mix but not by patient volume. In contrast, between‐hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT‐patient volume but not by case‐mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case‐mix is applied for NIHSS score.

Published
2023
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4. 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

5. Endovascular treatment in anterior circulation stroke beyond 6.5 hours after onset or time last seen well: results from the MR CLEAN Registry

Author

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

Subjects
medicine.medical_treatment, Perfusion scanning, GUIDELINES, lcsh:RC346-429, Brain Ischemia, EARLY MANAGEMENT, law.invention, 0302 clinical medicine, Randomized controlled trial, law, Modified Rankin Scale, Occlusion, Medicine, Prospective Studies, Registries, ACUTE ISCHEMIC-STROKE, 030212 general & internal medicine, Stroke, Original Research, Thrombectomy, OUTCOMES, medicine.diagnostic_test, Endovascular Procedures, Thrombolysis, THROMBECTOMY, Cardiology, INFARCTION, Cardiology and Cardiovascular Medicine, Life Sciences & Biomedicine, medicine.medical_specialty, Clinical Neurology, 03 medical and health sciences, Internal medicine, SCORE, Humans, lcsh:Neurology. Diseases of the nervous system, Ischemic Stroke, HEALTH-CARE PROFESSIONALS, Science & Technology, business.industry, Other Research Radboud Institute for Health Sciences [Radboudumc 0], CT ANGIOGRAPHY, medicine.disease, United States, Angiography, Propensity score matching, Neurosciences & Neurology, Neurology (clinical), business, 030217 neurology & neurosurgery
Abstract

BackgroundRandomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However, outcomes after EVT in these late window patients without perfusion imaging are largely unknown. We assessed their characteristics and outcomes in routine clinical practice.MethodsThe Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, multicentre study in the Netherlands, included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017. CT perfusion was no standard imaging modality. We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age, prestroke modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, Alberta Stroke Programme Early CT Score (ASPECTS), collateral status, location of occlusion and treatment with intravenous thrombolysis. Outcomes included 3-month mRS score, functional independence (defined as mRS 0–2), and death.ResultsOf 3264 patients who underwent EVT, 106 (3.2%) were treated beyond 6.5 hours (median 8.5, IQR 6.9–10.6), of whom 93 (87.7%) had unknown time of stroke onset. CT perfusion was not performed in 87/106 (80.2%) late window patients. Late window patients were younger (mean 67 vs 70 years, pConclusionsWithout the use of CT perfusion selection criteria, EVT in the 6.5–24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics. randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window.

Published
2021

6. Endovascular treatment in anterior circulation stroke beyond 6.5 hours after onset or time last seen well: results from the MR CLEAN Registry

Author

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

Subjects
Neurology. Diseases of the nervous system, RC346-429
Abstract

Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However, outcomes after EVT in these late window patients without perfusion imaging are largely unknown. We assessed their characteristics and outcomes in routine clinical practice.Methods The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, multicentre study in the Netherlands, included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017. CT perfusion was no standard imaging modality. We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age, prestroke modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, Alberta Stroke Programme Early CT Score (ASPECTS), collateral status, location of occlusion and treatment with intravenous thrombolysis. Outcomes included 3-month mRS score, functional independence (defined as mRS 0–2), and death.Results Of 3264 patients who underwent EVT, 106 (3.2%) were treated beyond 6.5 hours (median 8.5, IQR 6.9–10.6), of whom 93 (87.7%) had unknown time of stroke onset. CT perfusion was not performed in 87/106 (80.2%) late window patients. Late window patients were younger (mean 67 vs 70 years, p

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