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1. Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial.

Author

Olthuis, S.G.H., Pirson, F.A.V., Pinckaers, F.M.E., Hinsenveld, W.H., Nieboer, D., Ceulemans, A., Knapen, R.R.M.M., Robbe, M.M.Q., Berkhemer, O.A., Walderveen, Marianne A.A. van, Lycklama a Nijeholt, G.J., Uyttenboogaart, M., Schonewille, W.J., Sluijs, P.M. van der, Wolff, L., Voorst, H. van, Postma, A.A., Roosendaal, S.D., Hoorn, A. van der, Emmer, B.J., Krietemeijer, M.G.M., Doormaal, P.J. van, Roozenbeek, B., Goldhoorn, R.B., Staals, J., Ridder, I.R. de, Leij, C. van der, Coutinho, J.M., Worp, H.B. van der, Lo, R.T., Bokkers, R.P., Dijk, E.J. van, Boogaarts, H.D., Wermer, M.J., Es, A.C. van, Tuijl, J.H. van, Kortman, H.G., Gons, R.A., Yo, L.S., Vos, J.A., Laat, K.F. de, Dijk, L.C. van, Wijngaard, I.R. van den, Hofmeijer, J., Martens, J.M., Brouwers, P.J., Bulut, T., Remmers, M.J., Jong, T.E.A.M. de, Hertog, H.M. den, Hasselt, B.A. van, Rozeman, A.D., Elgersma, O.E.H., Veen, B. van der, Sudiono, D.R., Lingsma, H.F., Roos, Y.B.W.E.M., Majoie, C.B.L.M., Lugt, A. van der, Dippel, D.W., Zwam, W.H. van, Oostenbrugge, R.J. van, Olthuis, S.G.H., Pirson, F.A.V., Pinckaers, F.M.E., Hinsenveld, W.H., Nieboer, D., Ceulemans, A., Knapen, R.R.M.M., Robbe, M.M.Q., Berkhemer, O.A., Walderveen, Marianne A.A. van, Lycklama a Nijeholt, G.J., Uyttenboogaart, M., Schonewille, W.J., Sluijs, P.M. van der, Wolff, L., Voorst, H. van, Postma, A.A., Roosendaal, S.D., Hoorn, A. van der, Emmer, B.J., Krietemeijer, M.G.M., Doormaal, P.J. van, Roozenbeek, B., Goldhoorn, R.B., Staals, J., Ridder, I.R. de, Leij, C. van der, Coutinho, J.M., Worp, H.B. van der, Lo, R.T., Bokkers, R.P., Dijk, E.J. van, Boogaarts, H.D., Wermer, M.J., Es, A.C. van, Tuijl, J.H. van, Kortman, H.G., Gons, R.A., Yo, L.S., Vos, J.A., Laat, K.F. de, Dijk, L.C. van, Wijngaard, I.R. van den, Hofmeijer, J., Martens, J.M., Brouwers, P.J., Bulut, T., Remmers, M.J., Jong, T.E.A.M. de, Hertog, H.M. den, Hasselt, B.A. van, Rozeman, A.D., Elgersma, O.E.H., Veen, B. van der, Sudiono, D.R., Lingsma, H.F., Roos, Y.B.W.E.M., Majoie, C.B.L.M., Lugt, A. van der, Dippel, D.W., Zwam, W.H. van, and Oostenbrugge, R.J. van

Abstract

Item does not contain fulltext, BACKGROUND: Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6-24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA). METHODS: MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220. FINDINGS: Between Feb 2, 2018

Published
2023

2. Inter-rater reliability for assessing intracranial collaterals in patients with acute ischemic stroke: comparing 29 raters and an artificial intelligence-based software

Author

Wolff, L., Su, J., Loon, D. van, Es, A. van, Doormaal, P.J. van, Majoie, C., Zwam, W. van, Dippel, D., Jenniskens, S.F.M., Lugt, A. van der, Walsum, T. van, Radiology and nuclear medicine, ACS - Atherosclerosis & ischemic syndromes, Radiology & Nuclear Medicine, Neurology, Radiology and Nuclear Medicine, ACS - Microcirculation, Amsterdam Neuroscience - Neurovascular Disorders, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B05 Cerebral small vessel disease, and RS: Carim - B06 Imaging

Subjects
Reproducibility of results, OUTCOMES, Collateral circulation, Consensus, Ischemic stroke, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Brain Ischemia, Cerebral Angiography, Stroke, Artificial Intelligence, PERFUSION, SCORE, CT-ANGIOGRAPHY, Humans, Radiology, Nuclear Medicine and imaging, Neurology (clinical), BURDEN, Cardiology and Cardiovascular Medicine, Software, Algorithms, INTRAARTERIAL TREATMENT
Abstract

Purpose Outcome of endovascular treatment in acute ischemic stroke patients is depending on the collateral circulation maintaining blood flow to the ischemic territory. We evaluated the inter-rater reliability and accuracy of raters and an automated algorithm for assessing the collateral score (CS, range: 0–3) in acute ischemic stroke patients. Methods Baseline CTA scans with an intracranial anterior occlusion from the MR CLEAN study (n=500) were used. For each core lab CS, ten CTA scans with sufficient quality were randomly selected. After a training session in collateral scoring, all selected CTA scans were individually evaluated for a visual CS by three groups: 7 radiologists, 13 junior and 9 senior radiology residents. Two additional radiologists scored CS to be used as reference, with a third providing a CS to produce a 2 out of 3 consensus CS in case of disagreement. An automated algorithm was also used to compute CS. Inter-rater agreement was reported with intraclass correlation coefficient (ICC). Accuracy of visual and automated CS were calculated. Results 39 CTA scans were assessed (1 corrupt CTA-scan excluded). All groups showed a moderate ICC (0.689-0.780) in comparison to the reference standard. Overall human accuracy was 65± 7% and increased to 88± 5% for dichotomized CS (0–1, 2–3). Automated CS accuracy was 62%, and 90% for dichotomized CS. No significant difference in accuracy was found between groups with different levels of expertise. Conclusion After training, inter-rater reliability in collateral scoring was not influenced by experience. Automated CS performs similar to residents and radiologists in determining a collateral score.

Published
2022

3. Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion

Author

Langezaal, L.C.M., Hoeven, E.J.R.J. van der, Mont'Alverne, F.J.A., Carvalho, J.J.F. de, Lima, F.O., Dippel, D.W.J., Lugt, A. van der, R.T.H. lo, Boiten, J., Nijeholt, G.J.L.A., Staals, J., Zwam, W.H. van, Nederkoorn, P.J., Majoie, C.B.L.M., Gerber, J.C., Mazighi, M., Piotin, M., Zini, A., Vallone, S., Hofmeijer, J., Martins, S.O., Nolte, C.H., Szabo, K., Dias, F.A., Abud, D.G., Wermer, M.J.H., Remmers, M.J.M., Schneider, H., Rueckert, C.M., Laat, K.F. de, Yoo, A.J., Doormaal, P.J. van, Es, A.C.G.M. van, Emmer, B.J., Michel, P., Puetz, V., Audebert, H.J., Pontes-Neto, O.M., Vos, J.A., Kappelle, L.J., Algra, A., Schonewille, W.J., BASICS Study Grp, Klinische Neurowetenschappen, MUMC+: MA Med Staf Spec Neurologie (9), RS: Carim - B05 Cerebral small vessel disease, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, TechMed Centre, Clinical Neurophysiology, Neurology, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Radiology and Nuclear Medicine, ACS - Microcirculation, and Radiology & Nuclear Medicine

Subjects
medicine.medical_specialty, Endovascular therapy, law.invention, Randomized controlled trial, law, Internal medicine, Severity of illness, Occlusion, medicine, In patient, ddc:610, cardiovascular diseases, Stroke, Intention-to-treat analysis, business.industry, Basilar artery occlusion, General Medicine, THROMBECTOMY, medicine.disease, ISCHEMIC-STROKE, RESULTADO DE TRATAMENTO, cardiovascular system, Cardiology, INTRAARTERIAL, TRIAL, business
Abstract

Background The effectiveness of endovascular therapy in patients with stroke caused by basilar-artery occlusion has not been well studied.Methods We randomly assigned patients within 6 hours after the estimated time of onset of a stroke due to basilar-artery occlusion, in a 1:1 ratio, to receive endovascular therapy or standard medical care. The primary outcome was a favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 to 6, with 0 indicating no disability, 3 indicating moderate disability, and 6 indicating death) at 90 days. The primary safety outcomes were symptomatic intracranial hemorrhage within 3 days after the initiation of treatment and mortality at 90 days.Results A total of 300 patients were enrolled (154 in the endovascular therapy group and 146 in the medical care group). Intravenous thrombolysis was used in 78.6% of the patients in the endovascular group and in 79.5% of those in the medical group. Endovascular treatment was initiated at a median of 4.4 hours after stroke onset. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (risk ratio, 1.18; 95% confidence interval [CI], 0.92 to 1.50). Symptomatic intracranial hemorrhage occurred in 4.5% of the patients after endovascular therapy and in 0.7% of those after medical therapy (risk ratio, 6.9; 95% CI, 0.9 to 53.0); mortality at 90 days was 38.3% and 43.2%, respectively (risk ratio, 0.87; 95% CI, 0.68 to 1.12).Conclusions Among patients with stroke from basilar-artery occlusion, endovascular therapy and medical therapy did not differ significantly with respect to a favorable functional outcome, but, as reflected by the wide confidence interval for the primary outcome, the results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion. (Funded by the Dutch Heart Foundation and others; BASICS ClinicalTrials.gov number, NCT01717755; Netherlands Trial Register number, NL2500.)Endovascular Therapy for Basilar-Artery Stroke In a randomized trial involving 300 patients with basilar-artery stroke, endovascular thrombectomy was not significantly different from medical therapy with respect to a favorable functional outcome (modified Rankin scale score of 0 to 3) at 90 days, but a clinically significant benefit could not be excluded.

Published
2021

4. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED):an open-label, multicentre, randomised controlled trial

Author

Steen, W. van der, Graaf, R.A.V. de, Chalos, V., Lingsma, H.F., Doormaal, P.J. van, Coutinho, J.M., Emmer, B.J., Ridder, I. de, Zwam, W. van, Worp, H.B. van der, Schaaf, I. van der, Gons, R.A.R., Yo, L.S.F., Boiten, J., Wijngaard, I. van den, Hofmeijer, J., Martens, J., Schonewille, W., Vos, J.A., Tuladhar, A.M., Laat, K.F. de, Hasselt, B. van, Remmers, M., Vos, D., Rozeman, A., Elgersma, O., Uyttenboogaart, M., Bokkers, R.P.H., Tuijl, J. van, Boukrab, I., Berg, R. van den, Beenen, L.F.M., Roosendaal, S.D., Postma, A.A., Krietemeijer, M., Lycklama, G., Meijer, F.J.A., Hammer, S., Hoorn, A. van der, Yoo, A.J., Gerrits, D., Truijman, M.T.B., Zinkstok, S., Koudstaal, P.J., Manschot, S., Kerkhoff, H., Nieboer, D., Berkhemer, O., Wolff, L., Sluijs, P.M. van der, Voorst, H. van, Tolhuisen, M., Roos, Y.B.W.E.M., Majoie, C.B.L.M., Staals, J., Oostenbrugge, R.J. van, Jenniskens, S.F.M., Dijk, L.C. van, Hertog, H.M. den, Es, A.C.G.M. van, Lugt, A. van der, Dippel, D.W.J., Roozenbeek, B., MR CLEAN-MED Investigators, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Damage and Repair in Cancer Development and Cancer Treatment (DARE), Neurology, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, Radiology and Nuclear Medicine, ACS - Microcirculation, ACS - Pulmonary hypertension & thrombosis, ANS - Cellular & Molecular Mechanisms, Biomedical Engineering and Physics, Graduate School, ANS - Brain Imaging, ANS - Compulsivity, Impulsivity & Attention, Radiology & Nuclear Medicine, Public Health, Pediatric surgery, Radiology and nuclear medicine, RS: Carim - B05 Cerebral small vessel disease, MUMC+: MA Med Staf Spec Neurologie (9), Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, MUMC+: DA BV AIOS Radiologie (9), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), MUMC+: MA AIOS Neurologie (9), Klinische Neurowetenschappen, and MUMC+: MA Neurologie (3)

Subjects
Stroke/etiology, Adult, Brain Ischemia/therapy, Aspirin, Heparin, INTRAVENOUS ALTEPLASE, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Vascular damage Radboud Institute for Molecular Life Sciences [Radboudumc 16], General Medicine, THROMBECTOMY, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Magnetic Resonance Imaging, TIME, Brain Ischemia, Stroke, All institutes and research themes of the Radboud University Medical Center, Treatment Outcome, Aspirin/therapeutic use, REPERFUSION, Humans, Heparin/adverse effects, ACUTE ISCHEMIC-STROKE, Rare cancers Radboud Institute for Health Sciences [Radboudumc 9]
Abstract

BACKGROUND: Aspirin and unfractionated heparin are often used during endovascular stroke treatment to improve reperfusion and outcomes. However, the effects and risks of anti-thrombotics for this indication are unknown. We therefore aimed to assess the safety and efficacy of intravenous aspirin, unfractionated heparin, both, or neither started during endovascular treatment in patients with ischaemic stroke.METHODS: We did an open-label, multicentre, randomised controlled trial with a 2 × 3 factorial design in 15 centres in the Netherlands. We enrolled adult patients (ie, ≥18 years) with ischaemic stroke due to an intracranial large-vessel occlusion in the anterior circulation in whom endovascular treatment could be initiated within 6 h of symptom onset. Eligible patients had a score of 2 or more on the National Institutes of Health Stroke Scale, and a CT or MRI ruling out intracranial haemorrhage. Randomisation was done using a web-based procedure with permuted blocks and stratified by centre. Patients were randomly assigned (1:1) to receive either periprocedural intravenous aspirin (300 mg bolus) or no aspirin, and randomly assigned (1:1:1) to receive moderate-dose unfractionated heparin (5000 IU bolus followed by 1250 IU/h for 6 h), low-dose unfractionated heparin (5000 IU bolus followed by 500 IU/h for 6 h), or no unfractionated heparin. The primary outcome was the score on the modified Rankin Scale at 90 days. Symptomatic intracranial haemorrhage was the main safety outcome. Analyses were based on intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. This trial is registered with the International Standard Randomised Controlled Trial Number, ISRCTN76741621.FINDINGS: Between Jan 22, 2018, and Jan 27, 2021, we randomly assigned 663 patients; of whom, 628 (95%) provided deferred consent or died before consent could be asked and were included in the modified intention-to-treat population. On Feb 4, 2021, after unblinding and analysis of the data, the trial steering committee permanently stopped patient recruitment and the trial was stopped for safety concerns. The risk of symptomatic intracranial haemorrhage was higher in patients allocated to receive aspirin than in those not receiving aspirin (43 [14%] of 310 vs 23 [7%] of 318; adjusted OR 1·95 [95% CI 1·13-3·35]) as well as in patients allocated to receive unfractionated heparin than in those not receiving unfractionated heparin (44 [13%] of 332 vs 22 [7%] of 296; 1·98 [1·14-3·46]). Both aspirin (adjusted common OR 0·91 [95% CI 0·69-1·21]) and unfractionated heparin (0·81 [0·61-1·08]) led to a non-significant shift towards worse modified Rankin Scale scores.INTERPRETATION: Periprocedural intravenous aspirin and unfractionated heparin during endovascular stroke treatment are both associated with an increased risk of symptomatic intracranial haemorrhage without evidence for a beneficial effect on functional outcome.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

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

Author

Hartog, S.J. den, Lingsma, H.F., Doormaal, P.J. van, Hofmeijer, J., Yo, L.S., Majoie, C., Dippel, D.W., Jenniskens, S.F.M., Lugt, A. van der, Roozenbeek, B., Hartog, S.J. den, Lingsma, H.F., Doormaal, P.J. van, Hofmeijer, J., Yo, L.S., Majoie, C., Dippel, D.W., Jenniskens, S.F.M., Lugt, A. van der, and Roozenbeek, B.

Abstract

Item does not contain fulltext, 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 e

Published
2022

6. Estimation of treatment effects in observational stroke care data: comparison of statistical approaches

Author

Amini, M., Leeuwen, N. van, Eijkenaar, F., Graaf, R. de, Samuels, N., Oostenbrugge, R van, Wijngaard, I.R. van den, Doormaal, P.J. van, Roos, Y., Majoie, C., Roozenbeek, B., Dippel, D., Jenniskens, S.F.M., Burke, J., Lingsma, H.F., Amini, M., Leeuwen, N. van, Eijkenaar, F., Graaf, R. de, Samuels, N., Oostenbrugge, R van, Wijngaard, I.R. van den, Doormaal, P.J. van, Roos, Y., Majoie, C., Roozenbeek, B., Dippel, D., Jenniskens, S.F.M., Burke, J., and Lingsma, H.F.

Abstract

Contains fulltext : 287821.pdf (Publisher’s version ) (Open Access), INTRODUCTION: Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data. PATIENTS AND METHODS: We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions - i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT - on good functional outcome (modified Rankin Scale

Published
2022

7. Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study

Author

Steen, W. van der, Ende, N.A.M. van der, Kranendonk, K.R. van, Chalos, V., Oostenbrugge, R.J. van, Zwam, W.H. van, Roos, Y., Doormaal, P.J. van, Es, A. van, Lingsma, H.F., Majoie, C., Lugt, A. van der, Jenniskens, S.F.M., Dippel, D.W., Roozenbeek, B., Steen, W. van der, Ende, N.A.M. van der, Kranendonk, K.R. van, Chalos, V., Oostenbrugge, R.J. van, Zwam, W.H. van, Roos, Y., Doormaal, P.J. van, Es, A. van, Lingsma, H.F., Majoie, C., Lugt, A. van der, Jenniskens, S.F.M., Dippel, D.W., and Roozenbeek, B.

Abstract

Item does not contain fulltext, BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location. METHODS: We retrospectively analyzed data from the Dutch MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and MR CLEAN registry. We included adult patients with a large vessel occlusion in the anterior circulation who underwent endovascular treatment within 6.5 hours of stroke onset. We used univariable and multivariable logistic regression analyses to identify determinants of overall sICH occurrence, sICH within infarcted brain tissue, and sICH outside infarcted brain tissue. RESULTS: SICH occurred in 203 (6%) of 3313 included patients and was located within infarcted brain tissue in 50 (25%), outside infarcted brain tissue in 23 (11%), and both within and outside infarcted brain tissue in 116 (57%) patients. In 14 patients (7%), data on location were missing. Prior antiplatelet use, baseline systolic blood pressure, baseline plasma glucose levels, post-endovascular treatment modified treatment in cerebral ischemia score, and duration of procedure were associated with all outcome parameters. In addition, determinants of sICH within infarcted brain tissue included history of myocardial infarction (adjusted odds ratio, 1.65 [95% CI, 1.06-2.56]) and poor collateral score (adjusted odds ratio, 1.42 [95% CI, 1.02-1.95]), whereas determinants of sICH outside infarcted brain tissue included level of occlusion on computed tomography angiography (internal carotid artery or internal carotid artery terminus compared with M1: adjusted odds ratio, 1.79 [95% CI, 1.16-2.78]). CONCLUSIONS: Several factors, some potentially modifiable, are associated with sICH occurrence. Further studies should investigate whether modification of baseline systolic blood pressure or plasma glucose level could reduce the risk of sI

Published
2022

8. Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry

Author

Compagne, K.C.J., Kappelhof, M., Hinsenveld, W.H., Brouwer, J., Goldhoorn, R.B., Uyttenboogaart, M., Bokkers, R.P., Schonewille, W.J., Martens, J.M., Hofmeijer, J., Worp, H.B. van der, Lo, R.T., Keizer, K., Yo, L.S., Nijeholt, G.J., Hertog, H.M. den, Sturm, E.J.C., Brouwers, P., Walderveen, Marianne A.A. van, Wermer, M.J., Bruijn, S.F. de, Dijk, L.C. van, Boogaarts, H.D., Dijk, E.J. van, Tuijl, J.H. van, Peluso, J.P.P., Kort, P.L. de, Hasselt, B. van, Fransen, P.S., Schreuder, T., Heijboer, R.J., Jenniskens, S.F.M., Sprengers, M.E., Ghariq, E., Wijngaard, I.R. van den, Roosendaal, S.D., Meijer, A., Beenen, L.F., Postma, A.A., Berg, R van den, Yoo, A.J., Doormaal, P.J. van, Proosdij, M.P. van, Krietemeijer, M.G.M., Gerrits, D.G., Hammer, S., Vos, Janet R., Boiten, J., Coutinho, J.M., Emmer, B.J., Es, A. van, Roozenbeek, B., Roos, Y., Zwam, W.H. van, Oostenbrugge, R.J. van, Majoie, C., Dippel, D.W., Lugt, A. van der, Compagne, K.C.J., Kappelhof, M., Hinsenveld, W.H., Brouwer, J., Goldhoorn, R.B., Uyttenboogaart, M., Bokkers, R.P., Schonewille, W.J., Martens, J.M., Hofmeijer, J., Worp, H.B. van der, Lo, R.T., Keizer, K., Yo, L.S., Nijeholt, G.J., Hertog, H.M. den, Sturm, E.J.C., Brouwers, P., Walderveen, Marianne A.A. van, Wermer, M.J., Bruijn, S.F. de, Dijk, L.C. van, Boogaarts, H.D., Dijk, E.J. van, Tuijl, J.H. van, Peluso, J.P.P., Kort, P.L. de, Hasselt, B. van, Fransen, P.S., Schreuder, T., Heijboer, R.J., Jenniskens, S.F.M., Sprengers, M.E., Ghariq, E., Wijngaard, I.R. van den, Roosendaal, S.D., Meijer, A., Beenen, L.F., Postma, A.A., Berg, R van den, Yoo, A.J., Doormaal, P.J. van, Proosdij, M.P. van, Krietemeijer, M.G.M., Gerrits, D.G., Hammer, S., Vos, Janet R., Boiten, J., Coutinho, J.M., Emmer, B.J., Es, A. van, Roozenbeek, B., Roos, Y., Zwam, W.H. van, Oostenbrugge, R.J. van, Majoie, C., Dippel, D.W., and Lugt, A. van der

Abstract

Contains fulltext : 251533.pdf (Publisher’s version ) (Open Access), BACKGROUND: We evaluated data from all patients in the Netherlands who underwent endovascular treatment for acute ischemic stroke in the past 3.5 years, to identify nationwide trends in time to treatment and procedural success, and assess their effect on clinical outcomes. METHODS: We included patients with proximal occlusions of the anterior circulation from the second and first cohorts of the MR CLEAN (Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry (March 2014 to June 2016; June 2016 to November 2017, respectively). We compared workflow times and rates of successful reperfusion (defined as an extended Thrombolysis in Cerebral Infarction score of 2B-3) between cohorts and chronological quartiles (all included patients stratified in chronological quartiles of intervention dates to create equally sized groups over the study period). Multivariable ordinal logistic regression was used to assess differences in the primary outcome (ordinal modified Rankin Scale at 90 days). RESULTS: Baseline characteristics were similar between cohorts (second cohort n=1692, first cohort n=1488) except for higher age, poorer collaterals, and less signs of early ischemia on computed tomography in the second cohort. Time from stroke onset to groin puncture and reperfusion were shorter in the second cohort (median 185 versus 210 minutes; P<0.001 and 236 versus 270 minutes; P<0.001, respectively). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 66%; P<0.001). Functional outcome significantly improved (adjusted common odds ratio 1.23 [95% CI, 1.07-1.40]). This effect was attenuated by adjustment for time from onset to reperfusion (adjusted common odds ratio, 1.12 [95% CI, 0.98-1.28]) and successful reperfusion (adjusted common odds ratio, 1.13 [95% CI, 0.99-1.30]). Outcomes were consistent in the analysis per chronological quartile. CONCLUSIONS: Clinical outcomes after end

Published
2022

9. Collateral Circulation and Outcome in Atherosclerotic Versus Cardioembolic Cerebral Large Vessel Occlusion

Author

Guglielmi, V., LeCouffe, N.E., Zinkstok, S.M., Compagne, K.C.J., Eker, R., Treurniet, K.M., Tolhuisen, M.L., Worp, H.B. van der, Jansen, I.G.H., Oostenbrugge, R.J. van, Marquering, H.A., Dippel, D.W.J., Emmer, B.J., Majoie, C.B.L.M., Roos, Y.B.W.E.M., Coutinho, J.M., Lugt, A. van der, Zwam, W.H. van, Boiten, J., Vos, J.A., Mulder, M.J.H.L., Goldhoorn, R.J.B., Kappelhof, M., Schonewille, W.J., Wermer, M.J.H., Walderveen, M.A.A. van, Staals, J., Hofmeijer, J., Martens, J.M., Nijeholt, G.J.L.A., Roozenbeek, B., Bruijn, S.F. de, Dijk, L.C. van, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Uyttenboogaart, M., Eshghi, O., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Yo, L.S.F., Hertog, H.M. den, Sturm, E.J.C., Sprengers, M.E.S., Jenniskens, S.F.M., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Postma, A.A., Roosendaal, S.D., Kallen, B.F.W. van der, Wijngaard, I.R. van den, Es, A.C.G.M. van, Bot, J., Doormaal, P.J. van, Flach, H.Z., Lingsma, H.F., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Aaldering, N., Zweedijk, B., Khalilzada, M., Venema, E., Chalos, V., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Muijres, D., Jong, A. de, Hinsenveld, W., Berkhemer, O.A., Boers, A.M.M., Huguet, J., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Tolhuijsen, M.L., Alves, H., MR-CLEAN Registry Investigators, Neurology, Radiology and nuclear medicine, VU University medical center, Pediatric surgery, ACS - Atherosclerosis & ischemic syndromes, Radiology & Nuclear Medicine, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Graduate School, ACS - Microcirculation, ACS - Pulmonary hypertension & thrombosis, ANS - Neurovascular Disorders, Radiology and Nuclear Medicine, AGEM - Re-generation and cancer of the digestive system, AGEM - Digestive immunity, CCA - Imaging and biomarkers, ARD - Amsterdam Reproduction and Development, MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, RS: CARIM - R3.11 - Imaging, Promovendi CD, MUMC+: MA AIOS Neurologie (9), MUMC+: MA Med Staf Spec Neurologie (9), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), MUMC+: DA BV AIOS Radiologie (9), and MUMC+: MA Niet Med Staf Neurologie (9)

Subjects
Carotid Artery Diseases, Male, endovascular treatment, Original Contributions, FEATURES, EMBOLIC STROKES, Brain Ischemia, Modified Rankin Scale, Occlusion, Medicine, Advanced and Specialised Nursing, Registries, collateral circulation, ACUTE ISCHEMIC-STROKE, Stroke, HYPOPERFUSION, Aged, 80 and over, education.field_of_study, Brain, Atrial fibrillation, Middle Aged, THROMBECTOMY, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Collateral circulation, ETIOLOGY, Intracranial Embolism, Cardiology, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Female, Internal carotid artery, Cardiology and Cardiovascular Medicine, medicine.medical_specialty, atherothrombotic stroke, Population, Clinical Sciences, Clinical Neurology, UNDETERMINED SOURCE, CLASSIFICATION, All institutes and research themes of the Radboud University Medical Center, medicine.artery, Internal medicine, ischemic stroke, Humans, cardiovascular diseases, education, cardiac emboli, Aged, Advanced and Specialized Nursing, business.industry, Other Research Radboud Institute for Health Sciences [Radboudumc 0], medicine.disease, CT ANGIOGRAPHY, Stenosis, ATRIAL-FIBRILLATION, Neurology (clinical), business
Abstract

Supplemental Digital Content is available in the text., Background and Purpose— Due to chronic hypoperfusion, cervical atherosclerosis may promote cerebral collateral circulation. We hypothesized that patients with ischemic stroke due to cervical carotid atherosclerosis have a more extensive collateral circulation and better outcomes than patients with cardioembolism. We tested this hypothesis in a population of patients who underwent endovascular treatment for large vessel occlusion. Methods— From the MR-CLEAN Registry (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), we selected consecutive adult endovascular treatment patients (March 2014 to June 2016) with acute ischemic stroke due to anterior circulation large vessel occlusion and compared patients with cervical carotid artery stenosis >50% to those with cardioembolic etiology. The primary outcome was collateral score, graded on a 4-point scale. Secondary outcomes included the modified Rankin Scale (mRS) score and mortality at 90 days. We performed multivariable regression analyses and adjusted for potential confounders. Results— Of 1627 patients in the Registry, 190 patients with cervical carotid atherosclerosis and 476 with cardioembolism were included. Patients with cervical carotid atherosclerosis were younger (median 69 versus 76 years, P

Published
2019

10. Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated With Outcome

Author

Samuels, N., Graaf, Rob A. van de, Berg, Carlijn A. L. van den, Uniken Venema, Simone M., Bala, Kujtesa, Doormaal, P.J. van, Hertog, Heleen den, Schreuder, F.H.B.M., Lingsma, Hester F., Dippel, Diederik W.J., Samuels, N., Graaf, Rob A. van de, Berg, Carlijn A. L. van den, Uniken Venema, Simone M., Bala, Kujtesa, Doormaal, P.J. van, Hertog, Heleen den, Schreuder, F.H.B.M., Lingsma, Hester F., and Dippel, Diederik W.J.

Abstract

Item does not contain fulltext

Published
2021

11. Effect of First-Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke

Author

Hartog, S.J. den, Zaidat, O., Roozenbeek, B., Es, A. van, Bruggeman, A.A.E., Emmer, B.J., Majoie, C., Zwam, W.H. van, Wijngaard, I.R. van den, Doormaal, P.J. van, Lingsma, H.F., Dijk, E.J. van, Boogaarts, H.D., Vries, J. de, Pegge, S.A.H., Meijer, A., Straaten, T. van, Geerlings, A.L., Jenniskens, S.F.M., Burke, J.F., Dippel, D.W., Hartog, S.J. den, Zaidat, O., Roozenbeek, B., Es, A. van, Bruggeman, A.A.E., Emmer, B.J., Majoie, C., Zwam, W.H. van, Wijngaard, I.R. van den, Doormaal, P.J. van, Lingsma, H.F., Dijk, E.J. van, Boogaarts, H.D., Vries, J. de, Pegge, S.A.H., Meijer, A., Straaten, T. van, Geerlings, A.L., Jenniskens, S.F.M., Burke, J.F., and Dippel, D.W.

Abstract

Contains fulltext : 235752.pdf (Publisher’s version ) (Open Access), Background First-pass reperfusion (FPR) is associated with favorable outcome after endovascular treatment. It is unknown whether this effect is independent of patient characteristics and whether FPR has better outcomes compared with excellent reperfusion (Expanded Thrombolysis in Cerebral Infarction [eTICI] 2C-3) after multiple-passes reperfusion. We aimed to evaluate the association between FPR and outcome with adjustment for patient, imaging, and treatment characteristics to single out the contribution of FPR. Methods and Results FPR was defined as eTICI 2C-3 after 1 pass. Multivariable regression models were used to investigate characteristics associated with FPR and to investigate the effect of FPR on outcomes. We included 2686 patients of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Factors associated with FPR were as follows: history of hyperlipidemia (adjusted odds ratio [OR], 1.05; 95% CI, 1.01-1.10), middle cerebral artery versus intracranial carotid artery occlusion (adjusted OR, 1.11; 95% CI, 1.06-1.16), and aspiration versus stent thrombectomy (adjusted OR, 1.07; 95% CI, 1.03-1.11). Interventionist experience increased the likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated; 95% CI, 1.01-1.06). Adjusted for patient, imaging, and treatment characteristics, FPR remained associated with a better 24-hour National Institutes of Health Stroke Scale (NIHSS) score (-37%; 95% CI, -43% to -31%) and a better modified Rankin Scale (mRS) score at 3 months (adjusted common OR, 2.16; 95% CI, 1.83-2.54) compared with no FPR (multiple-passes reperfusion+no excellent reperfusion), and compared with multiple-passes reperfusion alone (24-hour NIHSS score, (-23%; 95% CI, -31% to -14%), and mRS score (adjusted common OR, 1.45; 95% CI, 1.19-1.78)). Conclusions FPR compared with multiple-passes reperfusion is associated with favorable outcome, independently of patient, i

Published
2021

12. Operator Versus Core Lab Adjudication of Reperfusion After Endovascular Treatment of Acute Ischemic Stroke

Author

Zhang, G., Treurniet, K.M., Jansen, I.G., Emmer, B.J., Berg, R. van den, Marquering, H.A., Uyttenboogaart, M., Jenniskens, S.F.M., Roos, Y., Doormaal, P.J. van, Es, A. van, Lugt, A. van der, Vos, J.A, Lycklama, A.N.G.J., Zwam, W.H. van, Shi, H., Yoo, A.J., Dijk, E.J. van, Geerlings, A.L., Straaten, T. van, Boogaarts, H.D., Dippel, D.W., Majoie, C., Radiology & Nuclear Medicine, Neurology, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Radiology and Nuclear Medicine, ANS - Neurovascular Disorders, ACS - Atherosclerosis & ischemic syndromes, ACS - Microcirculation, Graduate School, Radiology and nuclear medicine, Amsterdam Neuroscience - Neurovascular Disorders, RS: CARIM - R3.11 - Imaging, RS: CARIM - R3.03 - Cerebral small vessel disease, Beeldvorming, and MUMC+: DA BV Medisch Specialisten Radiologie (9)

Subjects
Male, CEREBRAL INFARCTION, OCCLUSION, medicine.medical_treatment, THERAPY, law.invention, Brain Ischemia, 0302 clinical medicine, STENT-RETRIEVER, Randomized controlled trial, law, Modified Rankin Scale, 030212 general & internal medicine, Stroke, Aged, 80 and over, medicine.diagnostic_test, Cerebral infarction, Endovascular Procedures, Infarction, Middle Cerebral Artery, Thrombolysis, THROMBECTOMY, Middle Aged, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Treatment Outcome, Cardiology, REVASCULARIZATION, Female, Cardiology and Cardiovascular Medicine, medicine.medical_specialty, infarction, Revascularization, 03 medical and health sciences, Internal medicine, medicine, Humans, Aged, Retrospective Studies, THROMBOLYSIS, Advanced and Specialized Nursing, middle cerebral artery, business.industry, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Digital subtraction angiography, medicine.disease, Cerebral Angiography, Clinical trial, INTRAVENOUS T-PA, Reperfusion, Neurology (clinical), business, logistic models, 030217 neurology & neurosurgery
Abstract

Background and Purpose— The modified Treatment In Cerebral Ischemia (mTICI) score is the standard method to quantify the degree of reperfusion after endovascular treatment in acute ischemic stroke. In clinical practice, it is commonly assessed by local operators after the procedure. In clinical trials and registries, mTICI is evaluated by an imaging core lab. The aim of this study was to compare operator mTICI with core lab mTICI scores in patients included in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Methods— All patients with an intracranial carotid or middle cerebral artery occlusion with anteroposterior and lateral digital subtraction angiography runs were included. Operators determined the mTICI score immediately after endovascular treatment. Core lab neuroradiologists were blinded to clinical characteristics and assessed mTICI scores based on pre- and postintervention digital subtraction angiography. The agreement between operator and core lab mTICI scores and their value in the prediction of outcome (score on modified Rankin Scale at 90 days) was determined. Results— In total, 1130 patients were included. The proportion of agreement between operator and core lab mTICI score was 56% (95% CI, 54%–59%). In 33% (95% CI, 31%–36%), mTICI was overestimated by operators. Operators reported a higher rate of successful reperfusion than the core lab (77% versus 67%; difference 10% [95% CI, 6%–14%]; P Conclusions— Operators tend to overestimate the degree of reperfusion compared with the core lab although this does not affect the accuracy of outcome prediction.

Published
2018

13. Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours The MR CLEAN Registry

Author

Hinsenveld, W.H., Ridder, I.R. de, Oostenbrugge, R.J. van, Vos, J.A., Groot, A.E., Coutinho, J.M., Nijeholt, G.J.L.A., Boiten, J., Schonewille, W.J., Dippel, D.W.J., Lugt, A. van der, Majoie, C.B.L.M., Roos, Y.B.W.E.M., Zwam, W.H. van, Jansen, I.G.H., Mulder, M.J.H.L., Goldhoorn, R.J.B., Compagne, K.C.J., Kappelhof, M., Wermer, M.J.H., Walderveen, M.A.A. van, Staals, J., Hofmeijer, J., Martens, J.M., Roozenbeek, B., Emmer, B.J., Bruijn, S.F. de, Dijk, L.C. van, Worp, H.B. van der, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Uyttenboogaart, M., Eshghi, O., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Yo, L.S.F., Hertog, H.M. den, Sturm, E.J.C., Sprengers, M.E.S., Jenniskens, S.F.M., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Postma, A.A., Roosendaal, S.D., Kallen, B.F.W. van der, Wijngaard, I.R. van den, Es, A.C.G.M. van, Bot, J., Doormaal, P.J. van, Flach, H.Z., Lingsma, H.F., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Aaldering, N., Zweedijk, B., Khalilzada, M., Venema, E., Chalos, V., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Muijres, D., Jong, A. de, Hinsenveld, W., Berkhemer, O.A., Boersc, A.M.M., Huguet, J., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Treurniet, K.M., Tolhuijsen, M.L., Alves, H., MR CLEAN Registry Investigators, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, MUMC+: MA Niet Med Staf Neurologie (9), Promovendi CD, MUMC+: MA Med Staf Spec Neurologie (9), MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA AIOS Neurologie (9), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), MUMC+: DA BV AIOS Radiologie (9), Psychiatrie & Neuropsychologie, Radiology and nuclear medicine, VU University medical center, Pediatric surgery, ACS - Atherosclerosis & ischemic syndromes, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Graduate School, Neurology, ANS - Neurovascular Disorders, Radiology and Nuclear Medicine, ACS - Microcirculation, ACS - Pulmonary hypertension & thrombosis, AGEM - Digestive immunity, AGEM - Re-generation and cancer of the digestive system, ARD - Amsterdam Reproduction and Development, Radiology & Nuclear Medicine, and Public Health

Subjects
Male, medicine.medical_specialty, Time Factors, workflow, medicine.medical_treatment, DOOR, endovascular procedures, DELAYS, Time-to-Treatment, All institutes and research themes of the Radboud University Medical Center, Modified Rankin Scale, medicine, Clinical endpoint, Humans, QUALITY, Registries, Lead (electronics), Stroke, Aged, Retrospective Studies, Aged, 80 and over, Advanced and Specialized Nursing, OUTCOMES, Groin, business.industry, delivery of health care, holidays, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Odds ratio, Middle Aged, THROMBECTOMY, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], medicine.disease, ADMISSION, stroke, Surgery, TIME, Observational Studies as Topic, medicine.anatomical_structure, ISCHEMIC-STROKE, Intravenous therapy, Female, Neurology (clinical), Cardiology and Cardiovascular Medicine, Complication, business
Abstract

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

Published
2019

14. Impact of single phase CT angiography collateral status on functional outcome over time: results from the MR CLEAN Registry

Author

Jansen, I.G.H., Mulder, M.J.H.L., Goldhoorn, R.J.B., Boers, A.M.M., Es, A.C.G.M. van, Yo, L.S.F., Hofmeijer, J., Martens, J.M., Walderveen, M.A.A. van, Kallen, B.F.W. van der, Jenniskens, S.F.M., Treurniet, K.M., Marqueriny, H.A., Sprengers, M.E.S., Schonewille, W.J., Bot, J.C.J., Nijeholt, G.J.L.A., Lingsma, H.F., Liebeskind, D.S., Boiten, J., Vos, J.A., Roos, Y.B.W.E.M., Oostenbrugge, R.J. van, Lugt, A. van der, Zwam, W.H. van, Dippel, D.W.J., Wijngaard, I.R. van den, Majoie, C.B.L.M., Coutinho, J.M., Wermern, M.J.H., Staals, J., Roozenbeek, B., Emmer, B.J., Bruijn, S.F. de, Dijk, L.C. van, Worp, H.B. van der, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Uyttenboogaart, M., Eshghi, O., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Hertog, H.M. den, Sturm, E.J.C., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Roosendaal, S.D., Es, A. van, Emmer, B., Bot, J., Doormaal, P.J. van, Flach, H.Z., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Zweedijk, B., Khalilzada, M., Venema, E., Chalos, V., Compagne, K.J., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Muijres, D., Jong, A. de, Hinseveld, W., Berkhemer, O.A., Huguet, J., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Kappelhof, M., Tolhuijsen, M.L., Alves, H., MR CLEAN Registry Investigators, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Clinical Neurophysiology, Neurology, Radiology & Nuclear Medicine, Public Health, MUMC+: MA AIOS Neurologie (9), Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, Promovendi CD, MUMC+: MA Neurologie (3), RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA Med Staf Spec Neurologie (9), Radiology and nuclear medicine, Amsterdam Neuroscience - Neurovascular Disorders, ACS - Atherosclerosis & ischemic syndromes, ANS - Neurovascular Disorders, ACS - Microcirculation, Graduate School, and Radiology and Nuclear Medicine

Subjects
Male, PREDICTOR, Computed Tomography Angiography, THERAPY, 030218 nuclear medicine & medical imaging, law.invention, Brain Ischemia, 0302 clinical medicine, Randomized controlled trial, Modified Rankin Scale, Time windows, law, ct angiography, REPERFUSION, Prospective Studies, Registries, Single phase, Stroke, intervention, Netherlands, Aged, 80 and over, medicine.diagnostic_test, Endovascular Procedures, General Medicine, Middle Aged, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Treatment Outcome, Cardiology, Female, LEPTOMENINGEAL COLLATERALS, STROKE, Adult, medicine.medical_specialty, Adolescent, Time to treatment, Collateral Circulation, 03 medical and health sciences, Young Adult, Internal medicine, SCORE, medicine, MANAGEMENT, Humans, Endovascular treatment, Aged, business.industry, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Recovery of Function, medicine.disease, n/a OA procedure, ENDOVASCULAR TREATMENT, Angiography, Surgery, Neurology (clinical), business, COMPUTED TOMOGRAPHIC ANGIOGRAPHY, 030217 neurology & neurosurgery
Abstract

BackgroundCollateral status modified the effect of endovascular treatment (EVT) for stroke in several randomized trials. We assessed the association between collaterals and functional outcome in EVT treated patients and investigated if this association is time dependent.MethodsWe included consecutive patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN) Registry (March 2014–June 2016) with an anterior circulation large vessel occlusion undergoing EVT. Functional outcome was measured on the modified Rankin Scale (mRS) at 90 days. We investigated the association between collaterals and mRS in the MR CLEAN Registry with ordinal logistic regression and if this association was time dependent with an interaction term. Additionally, we determined modification of EVT effect by collaterals compared with MR CLEAN controls, and also investigated if this was time dependent with multiplicative interaction terms.Results1412 patients were analyzed. Functional independence (mRS score of 0–2) was achieved in 13% of patients with grade 0 collaterals, in 27% with grade 1, in 46% with grade 2, and in 53% with grade 3. Collaterals were significantly associated with mRS (adjusted common OR 1.5 (95% CI 1.4 to 1.7)) and significantly modified EVT benefit (P=0.04). None of the effects were time dependent. Better collaterals corresponded to lower mortality (PConclusionIn routine clinical practice, better collateral status is associated with better functional outcome and greater treatment benefit in EVT treated acute ischemic stroke patients, independent of time to treatment. Within the 6 hour time window, a substantial proportion of patients with absent and poor collaterals can still achieve functional independence.

Published
2019

15. Periprocedural Intravenous Heparin During Endovascular Treatment for Ischemic Stroke: Results From the MR CLEAN Registry

Author

Graaf, R.A. van de, Chalos, V., Es, A.C.G.M. van, Emmer, B.J., Nijeholt, G.J.L.A., Worp, H.B. van der, Schonewille, W.J., Lugt, A. van der, Dippel, D.W.J., Lingsma, H.F., Roozenbeek, B., Dippel, D., Majoie, C., Roos, Y., Oostenbrugge, R. van, Zwam, W. van, Boiten, J., Vos, J.A., Jansen, I., Mulder, M., Goldhoorn, R.J., Compagne, K., Kappelhof, M., Schonewille, W., Coutinho, J., Wermer, M., Walderveen, M. van, Staals, J., Hofmeijer, J., Martens, J.M., Nijeholt, G.L.A., Emmer, B., Bruijn, S. de, Dijk, L. van, R. lo, Dijk, E. van, Boogaarts, H., Kort, P. de, Peluso, J., Berg, J. van den, Hasselt, B. van, Aerden, L., Dallinga, R., Uyttenboogaart, M., Eshghi, O., Schreuder, T., Heijboer, R., Keizer, K., Yo, L., Hertog, H. den, Sturm, E., Sprengers, M., Jenniskens, S., Berg, R. van den, Yoo, A., Beenen, L., Postma, A., Roosendaal, S., Kallen, B. van der, Wijngaard, I. van den, Es, A. van, Martens, J., Bot, J., Doormaal, P.J. van, Worp, B. van der, Flach, Z., Lingsma, H., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Aaldering, N., Zweedijk, B., Khalilzada, M., Venema, E., Geuskens, R., Straaten, T. van, Ergezen, S., Harmsma, R., Muijres, D., Jong, A. de, Hinseveld, W., Berkhemer, O., Boers, A., Huguet, J., Groot, P., Mens, M., Kranendonk, K. van, Treurniet, K., Tolhuijsen, M., Alves, H., MR CLEAN Registry Investigators, Radiology and nuclear medicine, VU University medical center, Pediatric surgery, ACS - Atherosclerosis & ischemic syndromes, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Neurology, Radiology & Nuclear Medicine, Public Health, Radiology and Nuclear Medicine, ANS - Neurovascular Disorders, MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA AIOS Neurologie (9), Promovendi CD, MUMC+: MA Med Staf Spec Neurologie (9), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, and MUMC+: DA BV AIOS Radiologie (9)

Subjects
Male, Original Contributions, medicine.medical_treatment, heparin, GUIDELINES, Brain Ischemia, law.invention, Randomized controlled trial, Modified Rankin Scale, law, Recombinant Proteins/therapeutic use, 80 and over, REPERFUSION, PROUROKINASE, Heparin/administration & dosage, Stroke, Aged, 80 and over, Anticoagulants/administration & dosage, Cerebral infarction, Endovascular Procedures, Heparin, Thrombolysis, Middle Aged, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], cerebral infarction, stroke, Recombinant Proteins, Treatment Outcome, thrombectomy, FOCAL CEREBRAL-ISCHEMIA, Anesthesia, Combination, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Drug Therapy, Combination, Female, Cardiology and Cardiovascular Medicine, Stroke/drug therapy, medicine.drug, Clinical Sciences, PROACT, All institutes and research themes of the Radboud University Medical Center, Fibrinolytic Agents, Drug Therapy, medicine, Humans, Urokinase-Type Plasminogen Activator/therapeutic use, Aged, Advanced and Specialized Nursing, business.industry, Fibrinolytic Agents/therapeutic use, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Anticoagulants, Brain Ischemia/drug therapy, Odds ratio, medicine.disease, Urokinase-Type Plasminogen Activator, Endovascular Procedures/methods, Ischemic stroke, Neurology (clinical), business
Abstract

Supplemental Digital Content is available in the text., Background and Purpose— Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety. Methods— Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction ≥2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome. Results— One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%–94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87–1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89–1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65–1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66–1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01–1.13). Conclusions— Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.

Published
2019

16. Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Author

Chalos, V., LeCouffe, N.E., Uyttenboogaart, M., Lingsma, H.F., Mulder, M.J.H.L., Venema, E., Treurniet, K.M., Eshghi, O., Worp, H.B. van der, Lugt, A. van der, Roos, Y.B.W.E.M., Majoie, C.B.L.M., Dippel, D.W.J., Roozenbeek, B., Coutinho, J.M., Oostenbrugge, R.J. van, Zwam, W.H. van, Boiten, J., Vos, J.A., Jansen, I.G.H., Goldhoorn, R.J.B., Schonewille, W.J., Wermer, M.J.H., Walderveen, M.A.A. van, Staals, J., Hofmeijer, J., Martens, J.M., Nijeholt, G.J.L.A., Emmer, B.J., Bruijn, S.F. de, Dijk, L.C. van, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Yo, L.S.F., Hertog, H.M. den, Sturm, E.J.C., Sprengers, M.E.S., Jenniskens, S.F.M., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Roosendaal, S.D., Kallen, B.F.W. van der, Wijngaard, I.R. van den, Es, A.C.G.M. van, Bot, J.C.J., Doormaal, P.J. van, Flach, H.Z., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Zweedijk, B., Khalilzada, M., Compagne, K.C.J., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Jong, A. de, Hinsenveld, W., Berkhemer, O.A., Boers, A.M.M., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Kappelhof, M., Tolhuijsen, M.L., Alves, H., MR CLEAN Registry Investigators, Neurology, Public Health, Radiology & Nuclear Medicine, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Radiology and nuclear medicine, ACS - Atherosclerosis & ischemic syndromes, Graduate School, ACS - Microcirculation, ANS - Neurovascular Disorders, Radiology and Nuclear Medicine, MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA Niet Med Staf Neurologie (9), Promovendi CD, MUMC+: MA Med Staf Spec Neurologie (9), and Clinical Neurophysiology

Subjects
Male, endovascular treatment, Time Factors, medicine.medical_treatment, RECANALIZATION, ANTERIOR CIRCULATION STROKE, THERAPY, law.invention, Brain Ischemia, Workflow, Disability Evaluation, Randomized controlled trial, Modified Rankin Scale, law, Risk Factors, REPERFUSION, Thrombolytic Therapy, Prospective Studies, Registries, Stroke, DIRECT MECHANICAL THROMBECTOMY, Netherlands, Original Research, Aged, 80 and over, OUTCOMES, Confounding, Endovascular Procedures, Atrial fibrillation, Thrombolysis, Middle Aged, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Combined Modality Therapy, stroke, Treatment Outcome, thrombectomy, Tissue Plasminogen Activator, Cardiology, Female, Cardiology and Cardiovascular Medicine, medicine.medical_specialty, thrombolysis, Cerebrovascular Procedures, All institutes and research themes of the Radboud University Medical Center, Fibrinolytic Agents, Internal medicine, large vessel occlusion, medicine, Humans, Aged, Ischemic Stroke, business.industry, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Odds ratio, Recovery of Function, medicine.disease, Cerebrovascular Disease/Stroke, Observational study, business
Abstract

Background It is unclear whether intravenous thrombolysis ( IVT ) with alteplase before endovascular treatment ( EVT ) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results Using multivariable regression, we evaluated the association of IVT + EVT with 90‐day functional outcome (modified Rankin Scale), mortality, reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT + EVT , and 324 (22%) with EVT alone. Patients treated with IVT + EVT had atrial fibrillation less often (16% versus 44%) and had better pre‐stroke modified Rankin Scale scores (pre‐stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT + EVT group (median 62 versus 68 minutes). Nontransferred IVT + EVT patients had longer door‐to‐groin‐puncture times (median 105 versus 94 minutes). IVT + EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI : 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI : 0.40–0.82). Successful reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions In this observational study, patients treated with IVT + EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT , but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT .

Published
2019

17. Safety and Outcome of Endovascular Treatment for Minor Ischemic Stroke: Results From the Multicenter Clinical Registry of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands

Author

Goldhoorn, R.B., Mulder, M.J.H.L., Jansen, I.G.H., Zwam, W.H. van, Staals, J., Lugt, A. van der, Dippel, D.W.J., Lingsma, H.F., Vos, J.A., Boiten, J., Wijngaard, I.R. van den, Majoie, C.B.L.M., Roos, Y.B.W.E.M., Oostenbrugge, R.J. van, Goldhoorn, R.J.B., Schonewille, W.J., Coutinho, J.M., Wermer, M.J.H., Walderveen, M.A.A. van, Hofmeijer, J., Martens, J.M., Nijeholt, G.J.L.A., Roozenbeek, B., Emmer, B.J., Bruijn, S.F. de, Dijk, L.C. van, Worp, H.B. van der, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Uyttenboogaart, M., Eshghi, O., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Yo, L.S.F., Hertog, H.M. den, Sturm, E.J.C., Sprengers, M.E.S., Jenniskens, S.F.M., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Roosendaal, S.D., Kallen, B.F.W. van der, Es, A. van, Emmer, B., Bot, J., Doormaal, P.J. van, Postma, A., Flach, H.Z., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Zweedijk, B., Khalilzada, M., Venema, E., Chalos, V., Compagne, K.J., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Muijres, D., Jong, A. de, Hinsenveld, W., Berkhemer, O.A., Boers, A.M.M., Huguet, J., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Treurniet, K.M., Kappelhof, M., Tolhuijsen, M.L., Alves, H., MR CLEAN Registry Investigators, Neurology, Radiology & Nuclear Medicine, Public Health, Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, MUMC+: MA Niet Med Staf Neurologie (9), Promovendi CD, RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA Med Staf Spec Neurologie (9), MUMC+: MA Neurologie (3), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, MUMC+: DA BV AIOS Radiologie (9), Amsterdam Neuroscience - Neurovascular Disorders, ACS - Atherosclerosis & ischemic syndromes, ACS - Microcirculation, Radiology and Nuclear Medicine, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), and Radiology and nuclear medicine

Subjects
Male, endovascular treatment, Time Factors, Severity of Illness Index, THERAPY, ANGIOGRAPHY, law.invention, Brain Ischemia, Disability Evaluation, 0302 clinical medicine, Randomized controlled trial, Modified Rankin Scale, law, Risk Factors, Occlusion, Prospective Studies, Registries, Stroke, Netherlands, Ischemic stroke, medicine.diagnostic_test, LARGE VESSEL OCCLUSION, Rehabilitation, Endovascular Procedures, minor symptoms, Middle Aged, THROMBECTOMY, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Treatment Outcome, Cerebrovascular Circulation, Cardiology, ANTERIOR CIRCULATION, Female, TRIAL, SCALE SCORE, Cardiology and Cardiovascular Medicine, Intracranial Hemorrhages, medicine.medical_specialty, Clinical Decision-Making, 03 medical and health sciences, large vessel oclusion, All institutes and research themes of the Radboud University Medical Center, Internal medicine, medicine, Humans, Artery occlusion, cardiovascular diseases, Aged, business.industry, Patient Selection, Other Research Radboud Institute for Health Sciences [Radboudumc 0], Recovery of Function, MILD, medicine.disease, Arterial occlusion, Angiography, Surgery, Observational study, Neurology (clinical), business, 030217 neurology & neurosurgery, INTRAARTERIAL TREATMENT
Abstract

Goal: Insufficient data is available about safety and efficacy of endovascular treatment (EVT) in patients with minor stroke symptoms because these patients were excluded from most randomized trials. We aimed to compare characteristics, functional outcome, and complications in patients with minor ischemic stroke National Institutes of Health Stroke Scale score ≤5 (NIHSS score ≤5) and moderate to severe ischemic stroke (NIHSS score ≥6) due to intracranial proximal artery occlusion of the anterior circulation who underwent EVT. Materials and Methods: We report patients with an anterior circulation occlusion who were included between March 2014 and June 2016 in the multicenter randomized clinical trial of EVT of acute ischemic stroke in the Netherlands Registry, a prospective, multicenter, observational study for stroke centers that perform EVT in the Netherlands. Minor ischemic stroke was defined as baseline NIHSS score of 5 or less. Primary outcome is the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes include symptomatic intracranial hemorrhage (sICH) and mortality. Findings: Seventy-one (5.5%) patients had a NIHSS score of 5 or less. Functional independence (mRS 0-2 at 90 days) was reached in 75% of these patients, compared to 40% of patients with NIHSS score of 6 or more. sICH occurred in 4% of patients, of which 1% occurred peri-interventionally. Death occurred in 6% of patients. Conclusions: Patients with minor ischemic stroke with an intracranial proximal arterial occlusion of the anterior circulation who underwent EVT have a high chance of favorable outcome and appear to have low occurrence of treatment-related sICH. Therefore, our results encourage the use of EVT for minor ischemic stroke in the absence of effect estimates from controlled studies.

Published
2019

18. Acute endovascular treatment of patients with ischemic stroke from intracranial large vessel occlusion and extracranial carotid dissection

Author

Compagne, K.C.J., Goldhoorn, R.B., Uyttenboogaart, M., Oostenbrugge, R.J. van, Zwam, W.H. van, Doormaal, P.J. van, Dippel, D.W.J., Lugt, A. van der, Emmer, B.J., Es, A.C.G.M. van, Majoie, C.B.L.M., Roos, Y.B.W.E.M., Boiten, J., Vos, J.A., Jansen, I.G.H., Mulder, M.J.H.L., Kappelhof, M., Schonewille, W.J., Coutinho, J.M., Wermer, M.J.H., Walderveen, M.A.A. van, Staals, J., Hofmeijer, J., Martens, J.M., Nijeholt, G.J.L., Roozenbeek, B., Bruijn, S.F. de, Dijk, L.C. van, Worp, H.B. van der, R.H. lo, Dijk, E.J. van, Boogaarts, H.D., Kort, P.L.M. de, Peluso, J.J.P., Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Aerden, L.A.M., Dallinga, R.J., Eshghi, O., Schreuder, T.H.C.M.L., Heijboer, R.J.J., Keizer, K., Yo, L.S.F., Hertog, H.M. den, Sturm, E.J.C., Sprengers, M.E.S., Jenniskens, S.F.M., Berg, R. van den, Yoo, A.J., Beenen, L.F.M., Postma, A.A., Roosendaal, S.D., Kallen, B.F.W. van der, Wijngaard, I.R. van den, Bot, J., Boiten, G.J., Flach, H.Z., Lingsma, H.F., Ghannouti, N. el, Sterrenberg, M., Puppels, C., Pellikaan, W., Sprengers, R., Elfrink, M., Meris, J. de, Vermeulen, T., Geerlings, A., Vemde, G. van, Simons, T., Rijswijk, C. van, Messchendorp, G., Bongenaar, H., Bodde, K., Kleijn, S., Lodico, J., Droste, H., Wollaert, M., Jeurrissen, D., Bos, E., Drabbe, Y., Aaldering, N., Zweedijk, B., Khalilzada, M., Venema, E., Chalos, V., Geuskens, R.R., Straaten, T. van, Ergezen, S., Harmsma, R.R.M., Muijres, D., Jong, A. de, Hinseveld, W., Berkhemer, O.A., Boers, A.M.M., Huguet, J., Groot, P.F.C., Mens, M.A., Kranendonk, K.R. van, Treurniet, K.M., Tolhuijsen, M.L., Alves, H., MR CLEAN Investigators, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Radiology and Nuclear Medicine, ANS - Neurovascular Disorders, Radiology and nuclear medicine, VU University medical center, Pediatric surgery, ACS - Atherosclerosis & ischemic syndromes, Klinische Neurowetenschappen, RS: Carim - B05 Cerebral small vessel disease, RS: CARIM - R3.03 - Cerebral small vessel disease, MUMC+: MA Niet Med Staf Neurologie (9), Promovendi CD, MUMC+: MA Neurologie (3), RS: Carim - B06 Imaging, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: CARIM - R3.11 - Imaging, MUMC+: MA Med Staf Spec Neurologie (9), MUMC+: DA BV AIOS Nucleaire Geneeskunde (9), RS: MHeNs - R1 - Cognitive Neuropsychiatry and Clinical Neuroscience, MUMC+: DA BV AIOS Radiologie (9), Radiology & Nuclear Medicine, Neurology, and Public Health

Subjects
endovascular treatment, medicine.medical_specialty, carotid dissection, CAD, 030204 cardiovascular system & hematology, lcsh:RC346-429, Carotid artery dissection, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Occlusion, SCORE, medicine, ischemic stroke, MANAGEMENT, REPERFUSION, ACUTE ISCHEMIC-STROKE, cardiovascular diseases, Endovascular treatment, Contraindication, lcsh:Neurology. Diseases of the nervous system, Original Research, tandem lesion, business.industry, MECHANICAL THROMBECTOMY, ARTERY DISSECTION, medicine.disease, Neurology, thrombectomy, Carotid artery occlusion, Cardiology, Neurology (clinical), Carotid dissection, business, 030217 neurology & neurosurgery, Large vessel occlusion, INTRAARTERIAL TREATMENT
Abstract

Introduction: Carotid artery dissection (CAD) and atherosclerotic carotid artery occlusion (ACAO) are major causes of a tandem occlusion in patients with intracranial large vessel occlusion (LVO). Presence of tandem occlusions may hamper intracranial access and potentially increases the risk of procedural complications of endovascular treatment (EVT). Our aim was to assess neurological, functional and technical outcome and complications of EVT for intracranial LVO in patients with CAD in comparison to patients with ACAO and to patients without CAD or ACAO.Methods: We analyzed data of the MR CLEAN trial intervention arm and MR CLEAN Registry, acquired in 16 Dutch EVT-centers. Primary outcome was the change in stroke severity by comparing the National Institute of Health Stroke Scale (NIHSS) score at 24-48 h after treatment vs. baseline. Secondary outcomes included reperfusion rate and symptomatic intracranial hemorrhage (sICH). We compared outcomes and complications between patients with CAD vs. patients with ACAO and patients without CAD or ACAO.Results: In total, we identified 74 (4.7%) patients with CAD, 92 (5.9%) patients with ACAO and 1398 (89.4%) patients without CAD or ACAO. Neurological improvement at short-term after EVT in patients with CAD was significantly better compared to ACAO (raw mean -5 vs. mean -1 NIHSS point; p = 0.03) and did not differ compared to patients without CAD or ACAO (-4 NIHSS points; p = 0.62). Rates of successful reperfusion in patients with CAD (47%) was comparable to patients with ACAO (47%; p = 1.00), but was less often achieved compared to patients without CAD or ACAO (58%; p = 0.08). Occurrence of sICH did not differ significantly between CAD patients (5%) and ACAO (11%; p = 0.33) or without CAD/ACAO (6%; p = 1.00).Conclusion: EVT in patients with intracranial LVO due to CAD results in neurological improvement comparable to patients without tandem occlusions. Therefore, carotid artery dissection by itself should not be a contraindication for endovascular treatment in stroke patients with intracranial large vessel occlusion. Although more challenging endovascular procedures are to be suspected in both patients with CAD or ACAO, accurate distinction between CAD and ACAO might influence clinical decision making as better clinical outcome can be expected in patients with CAD.

Published
2019

19. Endovascular treatment for acute ischaemic stroke in routine clinical practice: prospective, observational cohort study (MR CLEAN Registry)

Author

Jansen, I.G.H., Mulder, M.J.H.L., Goldhoorn, R.J.B., Emmer, B.J., Es, A.C.G.M. van, Roozenbeek, B., Schonewille, W.J., Berg, R. van den, Coutinho, J.M., Staals, J., Postma, A.A., Lycklama, G.J., Hofmeijer, J., Martens, J.M., Hertog, H.M. den, Sturm, F.J.C., Worp, H.B. van der, R.H. lo, Heijboer, R.J.J., Keizer, K., Uyttenboogaart, M., Eshghi, O., Wermer, M.J.H., Walderveen, M.A.A. van, Dijk, E.J. van, Boogaarts, H.D., Bruijn, S.F. de, Dijk, L.C. van, Berg, J.S.P. van den, Hasselt, B.A.A.M. van, Kort, P.L.M. de, Peluso, J.P.P., Schreuder, T.H.C.M.L., Aerden, L.A.M., Dallinga, R.J., Sprengers, M.E.S., Yo, L.S.F., Jenniskens, S.F.M., Roosendaal, S.D., Kallen, B.F.W. van der, Wijngaard, I.R. van den, Bot, J.C.J., Doormaal, P.J. van, Flach, H.Z., Venema, E., Lingsma, H.F., Beenen, L.F.M., Yoo, A.J., Boiten, J., Vos, J.A., Roos, Y.B.W.E.M., Oostenbrugge, R.J. van, Lugt, A. van der, Zwam, W.H. van, Dippel, D.W.J., Majoie, C.B.L.M., R Clean Registry Investigators m, Amsterdam Neuroscience - Neurovascular Disorders, Radiology and nuclear medicine, Promovendi CD, Klinische Neurowetenschappen, MUMC+: MA Niet Med Staf Neurologie (9), RS: CARIM - R3.03 - Cerebral small vessel disease, MUMC+: MA Med Staf Spec Neurologie (9), Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), MUMC+: MA Neurologie (3), RS: CARIM - R3.11 - Imaging, ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Neurology, Graduate School, ACS - Atherosclerosis & ischemic syndromes, ACS - Microcirculation, and ANS - Neurovascular Disorders

Subjects
Male, medicine.medical_specialty, RANDOMIZED CONTROLLED-TRIALS, medicine.medical_treatment, 030204 cardiovascular system & hematology, CLOT BURDEN SCORE, Brain Ischemia, Time-to-Treatment, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, Modified Rankin Scale, law, medicine, Humans, Registries, VALIDITY, METAANALYSIS, Aged, Netherlands, Thrombectomy, business.industry, Cerebral infarction, Research, MECHANICAL THROMBECTOMY, Endovascular Procedures, General Medicine, Thrombolysis, Odds ratio, Middle Aged, medicine.disease, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], Confidence interval, Surgery, Stroke, Outcome and Process Assessment, Health Care, THROMBOLYTIC THERAPY, INFARCT, Female, Observational study, business, Intracranial Hemorrhages, 030217 neurology & neurosurgery, Cohort study
Abstract

Contains fulltext : 193545.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To determine outcomes and safety of endovascular treatment for acute ischaemic stroke, due to proximal intracranial vessel occlusion in the anterior circulation, in routine clinical practice. DESIGN: Ongoing, prospective, observational cohort study. SETTING: 16 centres that perform endovascular treatment in the Netherlands. PARTICIPANTS: 1488 patients included in the Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry who had received endovascular treatment, including stent retriever thrombectomy, aspiration, and all alternative methods for acute ischaemic stroke within 6.5 hours from onset of symptoms between March 2014 and June 2016. MAIN OUTCOME MEASURES: The primary outcome was the modified Rankin Scale (mRS) score, ranging from 0 (no symptoms) to 6 (death) at 90 days after the onset of symptoms. Secondary outcomes were excellent functional outcome (mRS score 0-1), good functional outcome (mRS score 0-2), and favourable functional outcome (mRS score 0-3) at 90 days; score on the extended thrombolysis in cerebral infarction scale at the end of the intervention procedure; National Institutes of Health Stroke Scale score 24-48 hours after intervention; and complications that occurred during intervention, hospital admission, or three months' follow up period. Outcomes and safety variables in the MR CLEAN Registry were compared with the MR CLEAN trial intervention and control arms. RESULTS: A statistically significant shift was observed towards better functional outcome in patients in the MR CLEAN Registry compared with the MR CLEAN trial intervention arm (adjusted common odds ratio 1.30, 95% confidence interval 1.02 to 1.67) and the MR CLEAN trial control arm (1.85, 1.46 to 2.34). The reperfusion rate, with successful reperfusion defined as a score of 2B-3 on the extended thrombolysis in cerebral infarction score, was 58.7%, the same as for patients in the MR CLEAN trial. Duration from onset of stroke to start of endovascular treatment and from onset of stroke to successful reperfusion or last contrast bolus was one hour shorter for patients in the MR CLEAN Registry. Symptomatic intracranial haemorrhage occurred in 5.8% of patients in the MR CLEAN Registry compared with 7.7% in the MR CLEAN trial intervention arm and 6.4% in the MR CLEAN trial control arm. CONCLUSION: In routine clinical practice, endovascular treatment for patients with acute ischaemic stroke is at least as effective and safe as in the setting of a randomised controlled trial.

Published
2018

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