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

Author

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

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

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

Published
2022
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2. 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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3. Path from clinical research to implementation endovascular treatment of ischemic stroke in the Netherlands

Author

Eveline J.A. Wiegers, Kars C.J. Compagne, Paula M. Janssen, Esmee Venema, Jaap W. Deckers, Wouter J. Schonewille, Jan Albert Vos, Geert J. Lycklama à Nijeholt, Bob Roozenbeek, Jasper M. Martens, Jeannette Hofmeijer, Robert-Jan van Oostenbrugge, Wim H. van Zwam, Charles B.L.M. Majoie, Aad van der Lugt, H.F. Lingsma, Yvo B.W.E.M. Roos, Diederik W.J. Dippel, Jelis Boiten, Josje Brouwer, Sanne J. den Hartog, Wouter H. Hinsenveld, Manon Kappelhof, 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, Marieke J.H. Wermer, Marianne A.A. van Walderveen, Julie Staals, 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, Stefan D. Roosendaal, Bas F.W. van der Kallen, Ido R. van den Wijngaard, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Marc P. van Proosdij, G. Menno Krietemeijer, Jo P. Peluso, Rob Lo, 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, 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, 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, Damage and Repair in Cancer Development and Cancer Treatment (DARE), ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE), Clinical Neurophysiology, Radiology and Nuclear Medicine, ACS - Microcirculation, Amsterdam Neuroscience - Neurovascular Disorders, Neurology, ACS - Atherosclerosis & ischemic syndromes, MUMC+: MA Neurologie (3), Klinische Neurowetenschappen, MUMC+: Hersen en Zenuw Centrum (3), RS: Carim - B05 Cerebral small vessel disease, Beeldvorming, MUMC+: DA BV Medisch Specialisten Radiologie (9), RS: Carim - B06 Imaging, Public Health, Radiology & Nuclear Medicine, and Cardiology

Subjects
Male, SELECTION, medicine.medical_specialty, MEDLINE, ischemia, Rate ratio, THERAPY, symbols.namesake, NUMBER, medicine, Humans, Registries, Poisson regression, Endovascular treatment, Stroke, Aged, Netherlands, Aged, 80 and over, Advanced and Specialized Nursing, implementation science, business.industry, Patient Selection, Standard treatment, MECHANICAL THROMBECTOMY, Endovascular Procedures, Other Research Radboud Institute for Health Sciences [Radboudumc 0], 22/2 OA procedure, Middle Aged, medicine.disease, Disorders of movement Donders Center for Medical Neuroscience [Radboudumc 3], stroke, brain ischemia, Clinical trial, Treatment Outcome, Clinical research, INTRAVENOUS T-PA, thrombectomy, Emergency medicine, ONSET, symbols, Female, TRIAL, Neurology (clinical), Cardiology and Cardiovascular Medicine, business, Rare cancers Radboud Institute for Health Sciences [Radboudumc 9]
Abstract

Contains fulltext : 220823.pdf (Publisher’s version ) (Closed access) Before 2015, endovascular treatment (EVT) for acute ischemic stroke was considered a promising treatment option. Based on limited evidence, it was performed in several dedicated stroke centers worldwide on selected patients. Since 2015, EVT for patients with intracranial large vessel occlusion has quickly been implemented as standard treatment in many countries worldwide, supported by the revised international guidelines based on solid evidence from multiple clinical trials. We describe the development in use of EVT in the Netherlands before, during, and after the pivotal EVT trials. We used data from all patients who were treated with EVT in the Netherlands from January 2002 until December 2018. We undertook a time-series analysis to examine trends in the use of EVT using Poisson regression analysis. Incidence rate ratios per year with 95% CIs were obtained to demonstrate the impact and implementation after the publication of the EVT trial results. We made regional observation plots, adjusted for stroke incidence, to assess the availability and use of the treatment in the country. In the buildup to the MR CLEAN (Multicenter Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands), a slow increase of EVT patients was observed, with 0.2% of all ischemic stroke patients receiving EVT. Before the trial results were formally announced, a statistically significant increase in EVT-treated patients per year was observed (incidence rate ratio, 1.72 [95% CI, 1.46-2.04]), and after the trial publication, an immediate steep increase was seen, followed by a more gradual increase (incidence rate ratio, 2.14 [95% CI, 1.77-2.59]). In 2018, the percentage of ischemic stroke patients receiving EVT increased to 5.8%. A well-developed infrastructure, a pragmatic approach toward the use of EVT in clinical practice, in combination with a strict adherence by the regulatory authorities to national evidence-based guidelines has led to successful implementation of EVT in the Netherlands. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT in all regions of the country.

Published
2020

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