Abstract TMP2: Reduction of Time to Endovascular Treatment and Improved Outcomes After Ischemic Stroke in Routine Clinical Practice: Comparison of the MR CLEAN Registry First and Second Cohorts

Introduction: Outcomes after endovascular treatment (EVT) for acute ischemic stroke are highly time dependent, but whether active reduction of time to treatment leads to better outcome has not been demonstrated. We compared data of the two subsequent MR CLEAN Registry cohorts, comprising all patients in the Netherlands who had EVT for acute ischemic stroke from 2014-2017, for a trend in time to treatment and its association with outcome. Methods: We compared workflow, successful reperfusion (eTICI 2B-3), NIHSS at 24h, functional outcome (mRS) at 90 days, occurrence of symptomatic intracranial hemorrhage (sICH) and mortality in patients with ischemic stroke and a proximal intracranial occlusion in the anterior circulation included in the second cohort of the Registry (June 2016-November 2017; n = 1779) to those in patients included in the first cohort (March 2014-June 2016; n = 1526) using logistic regression. Results: Baseline NIHSS was 16 in both cohorts. Times from onset-to-groin and onset-to-reperfusion were shorter in the second cohort than in the first (185 versus 210 minutes; p<0.01 and 238 versus 270 minutes; p<0.01, respectively) (Figure 1). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 58%; p<0.01). Rates of sICH and mortality did not differ (5.9% versus 5.7%; p=0.94 and 29% versus 29%; p=0.60). However, follow-up NIHSS was lower (median 10 versus 11; p<0.001) and more patients achieved functional independence at 90 days (42.6% versus 38.9%; p = 0.012) in the second cohort (Figure 1). In a logistic regression model, the difference in good outcome between the two cohorts (aOR 1.27; 95%CI 1.08-1.50) was reduced after additional adjustment for time to reperfusion (aOR 1.15; 95%CI 0.96-1.36) as well as successful reperfusion (aOR 1.16; 95%CI 0.95-1.41). Discussion: Our data show that outcomes after EVT in routine clinical practice are improving, likely attributable to improved workflow and experience.

Download Full-text

Endovascular treatment for calcified cerebral emboli in patients with acute ischemic stroke

Journal of Neurosurgery ◽

10.3171/2020.9.jns201798 ◽

2021 ◽

pp. 1-11

Author(s):

Agnetha A. E. Bruggeman ◽

Manon Kappelhof ◽

Nerea Arrarte Terreros ◽

Manon L. Tolhuisen ◽

Praneeta R. Konduri ◽

...

Keyword(s):

Ischemic Stroke ◽

The Netherlands ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Functional Independence ◽

First Line ◽

Multicenter Randomized Controlled Trial ◽

Intravenous Alteplase ◽

Mr Clean

OBJECTIVE Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE. METHODS The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients. RESULTS The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44–1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28–0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64–2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04). CONCLUSIONS While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.

Download Full-text

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000491553 ◽

2018 ◽

Vol 46 (1-2) ◽

pp. 40-45 ◽

Cited By ~ 6

Author(s):

Andreia Carvalho ◽

Mariana Rocha ◽

Marta Rodrigues ◽

Tiago Gregório ◽

Henrique Costa ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Study Population ◽

Large Heterogeneity ◽

Definition Of ◽

Better Than

Background: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83–86] proposed a revised mTICI scale that includes a 2c grade (rTICI). Methods: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. Results: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13–19) and ASPECTS of 8 (7–9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18–0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14–10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80–27.82) but not in symptomatic ICH. Conclusions: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

Download Full-text

Age and Outcome after Endovascular Treatment in Anterior Circulation Large-Vessel Occlusion Stroke: ETIS Registry Results

Cerebrovascular Diseases ◽

10.1159/000512203 ◽

2020 ◽

pp. 1-10

Author(s):

Stephanos Finitsis ◽

Jonathan Epstein ◽

Sebastien Richard ◽

Romain Bourcier ◽

Igor Sibon ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Functional Independence ◽

Patient Age ◽

Poor Prognostic Factor ◽

Patient Âgé ◽

Positive Effect

Background: Increasing patient age has been identified in clinical trials as a poor prognostic factor for functional independence after endovascular treatment (EVT) for acute ischemic stroke. These findings may not be fully generalizable to clinical practice due to strict inclusion and exclusion criteria in these trials. We aim to assess and quantify the association of patient age, especially in patients >80 and >90 years old, with functional outcome after EVT in current, everyday clinical practice. Methods: The ETIS (Endovascular Treatment in Ischemic Stroke) Registry is an ongoing, prospective, observational study of 6 comprehensive stroke centers in France. We analyzed 1,708 patients treated between January 2017 and December 2018 and assessed the association of patient age with functional outcome adjusting for demographic and procedural predictors of functional outcome. Results: The positive effect of mechanical thrombectomy diminished significantly with increasing age: compared to the 18–80 years age group, the odds for achieving a good functional outcome at 90 days after the procedure decreased in the 80–90 and >90 years groups (multilevel OR: 0.38, 95% CI: 0.28–0.51 and OR: 0.2, 95% CI: 0.09–0.45, respectively, p < 0.001). Increasing age was associated with increased mortality (multilevel OR: 2.46, 95% CI: 1.72–3.54 for the 80–90 years group and multilevel OR: 5.49, 95% CI: 2.97–10.16 for the >90 years group). Conclusion: Patient age is strongly associated with functional outcome after EVT for acute ischemic stroke. The positive effect of thrombectomy persists in older age groups, even after adjustment for prognostic factors related to poor functional outcome. Stroke physicians should provide EVT irrespective of the patient’s age.

Download Full-text

Abstract T MP11: Does Onset To Recanalization Time Influence The Effect Of Penumbra Pattern On Clinical Outcomes In Acute Ischemic Stroke Patients Receiving Endovascular Treatment?

Stroke ◽

10.1161/str.46.suppl_1.tmp11 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jong-Won Chung ◽

Hong-Kyun Park ◽

Mi Hwa Yang ◽

Myung Suk Jang ◽

Beom Joon Kim ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Hemorrhagic Transformation ◽

Absolute Difference ◽

Infarct Core ◽

Anterior Circulation ◽

Stroke Registry ◽

Safety Outcome

Background: Whether penumbra pattern (PP) can identify patients who are most likely to benefit from endovascular treatment (EVT) for acute ischemic stroke remains unclear. We aimed to establish whether onset to recanalization time modifies the effect of PP on outcomes of EVT. Methods: Based on a prospective stroke registry database, we identified patients with acute ischemic stroke who underwent perfusion and diffusion MRI before EVT, had anterior circulation stroke and received EVT within 12 hours of symptom onset, and whose recanalization was confirmed during EVT (mTICI ≥ 2b). Favorable PP was defined as predicted infarct core ≤ 70 ml, and a ratio between the volume of critically hypoperfused tissue (Tmax > 6s) and the ischemic core of 1.8 or more with their absolute difference of 15 mL or more. Onset to recanalization time was dichotomized by median value. Primary outcome was functional independence defined as a modified Rankin Scale score of 0 - 2 at 3 months. Safety outcome was symptomatic hemorrhagic transformation. Results: Among 72 eligible patients, the mean age was 44.0 years and median initial NIHSS score was 14 (IQR, 9 - 19). Favorable PP was detected in 58 patients (80.6%), and median onset to recanalization time was 233 min (range 180 - 371). Among all study subjects, the proportion of functional independence was higher in those with favorable PP compared to those without it (62.1% vs. 7.1%; OR, 21.27; 95% CI, 2.60 - 174.06; P < 0.001), but was not different between early and late recanalization groups (61.1% vs. 41.7%; OR, 2.20; 95% CI, 0.86 - 5.65; P = 0.099). Favorable PP was associated with functional independence in either early recanalization (75.0% vs. 12.5%; P = 0.003) or late recanalization groups (50.0% vs. 0%; P = 0.030). For functional independence, there was no interaction between the PP and onset to recanalization time (P = 0.751). No patients developed symptomatic hemorrhagic transformation. Conclusions: Contrary to previous knowledge, this retrospective analysis shows that favorable PP may predict functional independence independent of onset to recanalization time.

Download Full-text

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014619 ◽

2019 ◽

Vol 11 (9) ◽

pp. 866-873 ◽

Cited By ~ 10

Author(s):

Ivo GH Jansen ◽

Maxim JHL Mulder ◽

Robert-Jan B Goldhoorn ◽

Anna MM Boers ◽

Adriaan CGM van Es ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Time Window ◽

Functional Independence ◽

Time Dependent ◽

Vessel Occlusion ◽

Treatment Benefit ◽

Mr Clean

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 (P<0.001), but not to lower rates of symptomatic intracranial hemorrhage (P=0.14).ConclusionIn 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.

Download Full-text

Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry

Neurology ◽

10.1212/wnl.0000000000009764 ◽

2020 ◽

Vol 95 (2) ◽

pp. e131-e139 ◽

Cited By ~ 1

Author(s):

Adrien E. Groot ◽

Kilian M. Treurniet ◽

Ivo G.H. Jansen ◽

Hester F. Lingsma ◽

Wouter Hinsenveld ◽

...

Keyword(s):

Older Adults ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Odds Ratio ◽

Absolute Risk ◽

Anterior Circulation ◽

Younger Patients ◽

Mr Clean

ObjectiveTo explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).MethodsWe included consecutive patients (2014–2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome.ResultsOf the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24–0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33–4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04–5.10 vs 2.00, 95% CI 1.56–2.57, pinteraction = 0.026).ConclusionOlder age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.

Download Full-text

MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion—study protocol for a randomized clinical trial

Trials ◽

10.1186/s13063-021-05063-5 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Kilian M. Treurniet ◽

◽

Natalie E. LeCouffe ◽

Manon Kappelhof ◽

Bart J. Emmer ◽

...

Keyword(s):

Clinical Trial ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Clinical Equipoise ◽

Anterior Circulation ◽

Early Reperfusion ◽

Link Type ◽

Increased Risk ◽

Mr Clean

Abstract Background Endovascular treatment (EVT) has greatly improved the prognosis of acute ischemic stroke (AIS) patients with a proximal intracranial large vessel occlusion (LVO) of the anterior circulation. Currently, there is clinical equipoise concerning the added benefit of intravenous alteplase administration (IVT) prior to EVT. The aim of this study is to assess the efficacy and safety of omitting IVT before EVT in patients with AIS caused by an anterior circulation LVO. Methods MR CLEAN-NO IV is a multicenter randomized open-label clinical trial with blinded outcome assessment (PROBE design). Patients ≥ 18 years of age with a pre-stroke mRS < 3 with an LVO confirmed on CT angiography/MR angiography eligible for both IVT and EVT are randomized to receive either IVT (0.9 mg/kg) followed by EVT, or direct EVT in a 1:1 ratio. The primary objective is to assess superiority of direct EVT. Secondarily, non-inferiority of direct EVT compared to IVT before EVT will be explored. The primary outcome is the score on the modified Rankin Scale at 90 days. Ordinal regression with adjustment for prognostic variables will be used to estimate treatment effect. Secondary outcomes include reperfusion graded with the eTICI scale after EVT and stroke severity (National Institutes of Health Stroke Scale) at 24 h. Safety outcomes include intracranial hemorrhages scored according to the Heidelberg criteria. A total of 540 patients will be included. Discussion IVT prior to EVT might facilitate early reperfusion before EVT or improved reperfusion rates during EVT. Conversely, among other potential adverse effects, the increased risk of bleeding could nullify the beneficial effects of IVT. MR CLEAN-NO IV will provide insight into whether IVT is still of added value in patients eligible for EVT. Trial registration www.isrctn.com: ISRCTN80619088. Registered on 31 October 2017.

Download Full-text

Outcome of endovascular treatment within and beyond 6 h without perfusion software

Scientific Reports ◽

10.1038/s41598-021-84857-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Zhen Jing ◽

Hao Li ◽

Shengming Huang ◽

Min Guan ◽

Yongxin Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

General Anesthesia ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Symptom Onset ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Group A ◽

Group B

AbstractEndovascular treatment (EVT) has been accepted as the standard of care for patients with acute ischemic stroke. The aim of the present study was to compare clinical outcomes of patients who received EVT within and beyond 6 h from symptom onset to groin puncture without perfusion software in Guangdong district, China. Between March 2017 and May 2018, acute ischemic stroke patients who received EVT from 6 comprehensive stroke centers, were enrolled into the registry study. In this subgroup study, we included all patients who had acute proximal large vessel occlusion in the anterior circulation. The demographic, clinical and neuroimaging data were collected from each center. A total of 192 patients were included in this subgroup study. They were divided into two groups: group A (n = 125), within 6 h; group B (n = 67), 6–24 h from symptom onset to groin puncture. There were no substantial differences between these two groups in terms of 90 days favorable outcome (modified Rankin scale [mRS] ≤ 2, P = 0.051) and mortality (P = 0.083), and the risk of symptomatic intracranial hemorrhage at 24 h (P = 0.425). The NIHSS (median 16, IQR12-20, group A; median 12, IQR8-18, group B; P = 0.009) and ASPECTS (median 10, IQR8-10, group A; median 9, IQR8-10, group B; P = 0.034) at baseline were higher in group A. The anesthesia method (general anesthesia, 21.3%, group A vs. 1.5% group B, P = 0.001) were also statistically different between the two groups. The NIHSS and ASPECTS were higher, and general anesthesia was also more widely used in group A. Clinical outcomes were not significantly different within 6 h versus 6–24 h from symptom onset to groin puncture in this real world study.

Download Full-text

Abstract 181: Determinants of Intracranial Atherosclerotic Enhancement on Vessel Wall MRI in Patients with Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.181 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adam de Havenon ◽

Nabeel Chauhan ◽

Jennifer Majersik ◽

David Tirschwell ◽

Ka-Ho Wong ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Vessel Wall ◽

Recurrent Stroke ◽

Pulse Sequences ◽

High Rate ◽

Stroke Recurrence ◽

Anterior Circulation ◽

Post Contrast

Introduction: Enhancing intracranial atherosclerotic plaque on high-resolution vessel wall MRI (vwMRI) is a reliable marker of recent thromboembolism, and confers a recurrent stroke risk of up to 30% a year. Post-contrast plaque enhancement (PPE) on vwMRI is thought to represent inflammation, but studies have not fully examined the clinical, serologic or radiologic factors that contribute to PPE. Methods: Inpatients with acute ischemic stroke due to intracranial atherosclerosis were prospectively enrolled at a single center from 2015-16. vwMRI was performed on a 3T Siemens Verio and included 3D DANTE pulse sequences, pre- and post-contrast (for PPE identification). Three experienced neuroradiologists interpreted vwMRI using a validated multicontrast technique. The Chi-squared, Fisher’s Exact, and Student’s t-test were used for intergroup differences, and logistic regression was fitted to the primary outcome of PPE. Results: Inclusion criteria were met by 35 patients. Atherosclerotic plaques were in the anterior circulation in 21/35 (60%) and PPE was diagnosed in 20/35 (57%) of stroke parent arteries. PPE predictors are shown in Table 1 with logistic regression in Table 2 . Conclusion: PPE is associated with stenosis, which was expected, but the association with HgbA1c is novel. All patients with HgbA1c >8 had PPE and a one point HgbA1c rise increased the odds of PPE 3-fold. Hyperglycemia induces vascular oxidative stress by generating reactive oxygen species, quenching nitric oxide, and triggering an inflammatory cascade. Given the high rate of stroke recurrence in PPE patients, aggressive HgbA1c reduction may be a viable treatment target and warrants additional study.

Download Full-text