scholarly journals Mehanička trombektomija – nova metoda liječenja akutnog ishemijskog moždanog udara

2021 ◽  
Vol 57 (4) ◽  
pp. 328-340
Author(s):  
Boris Bezak ◽  
Slavica Kovačić ◽  
Marina Bralić ◽  
David Bonifačić ◽  
Siniša Knežević ◽  
...  
Keyword(s):  
Mr Clean

U zadnjem desetljeću paradigma liječenja akutnog ishemijskog moždanog udara značajno je promijenjena. Za razliku od nekadašnjeg pasivnog pristupa koji je podrazumijevao medikamentoznu terapiju i medicinsko praćenje, danas se primjenjuje aktivno liječenje koje uključuje intravensku trombolizu i mehaničku trombektomiju. Mehanička trombektomija počela se provoditi početkom ovog stoljeća, no značajan procvat metode započeo je objavom nekoliko multicentričnih randomiziranih studija (MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, THRACE, PISTE) koje su 2015. godine potvrdile dobrobit ove metode liječenja. Danas je dokazano da je mehanička trombektomija povoljna i poželjna metoda liječenja bolesnika s akutnim ishemijskim moždanim udarom. Razvoj novih dijagnostičkih uređaja i standardizacija protokola snimanja omogućila je objektivniju procjenu stupnja oštećenja parenhima mozga, što je izravno utjecalo na odluku o daljnjem liječenju. Danas je postupak mehaničke trombektomije moguće provesti unutar 24 sata od nastupa simptoma, što su potvrdile i multicentrične randomizirane studije, DAWN i DEFUSE 3. Svakodnevni napredak mehaničke trombektomije doveo je do liječenja i distalnijih okluzija, poput M2 i M3 segmenta srednje moždane arterije i proksimalnih okluzija anteriorne i posteriorne moždane cirkulacije. Istovremeno je neurointervencijski tim postao veoma važna karika u lancu liječenja bolesnika s moždanim udarom. Nedavnom implementacijom mehaničke trombektomije u standardan protokol liječenja bolesnika s akutnim ishemijskim moždanim udarom u sve kliničke bolničke centre u Republici Hrvatskoj, bolesnicima koji borave u Republici Hrvatskoj omogućeno je liječenje najsuvremenijom metodom, sukladno najnovijim smjernicama.

Japan 1975: Mr. Clean Muddles Through

Asian Survey ◽  
1976 ◽  
Vol 16 (1) ◽  
pp. 31-41 ◽  
Author(s):  
Chalmers Johnson
Keyword(s):  
Mr Clean

scholarly journals Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands

2021 ◽  
pp. neurintsurg-2020-017017
Author(s):  
Henk van Voorst ◽  
Wolfgang G Kunz ◽  
Lucie A van den Berg ◽  
Manon Kappelhof ◽  
Floor M E Pinckaers ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Healthcare Costs ◽  
Large Vessel ◽  
Secondary Outcome ◽  
Vessel Occlusion ◽  
Time To Treatment ◽  
Stroke Population ◽  
Life Years ◽  
Mr Clean

BackgroundThe effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population.MethodsA Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs.ResultsEVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: −65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs.ConclusionOne-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.

scholarly journals Schlaganfall aus der Perspektive des Neurologen (Teil 2): Neues in der Akutbehandlung

Praxis ◽  
2016 ◽  
Vol 105 (10) ◽  
pp. 555-562
Author(s):  
Patrick Schur ◽  
Andreas Luft
Keyword(s):  
State Of The Art ◽  
Intravenöse Thrombolyse ◽  
Intraarterielle Thrombolyse ◽  
Mr Clean

Zusammenfassung. In der letzten Praxis-Ausgabe (9/2016) wurde im Artikel mit dem Titel «Neues in der Akutdiagnostik» über die relevanten Faktoren zur Erweiterung der thrombolytischen Prozeduren ausserhalb der bisherigen Thrombolyse-Einschlusskriterien berichtet. Die rasche klinische und bildgebende Identifizierung der Patienten, die von einer endovaskulären Therapie anhand des «Target Mismatch» profitieren, ist ein weiterer Schlüssel im Wettlauf mit der Zeit. Trotz der Kontraindikationen für eine IVT (intravenöse Thrombolyse) können die Vorteile der mechanischen devices es erlauben, einen Thrombus rasch, komplett und vor allem mit besserem Outcome zu entfernen. Die IAT (intraarterielle Thrombolyse) hat durch die neuen Resultate in den randomisiert kontrollierten Studien MR-CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME und REVASCAT an Bedeutung gewonnen. Im folgenden Artikel werden der state-of-the-art der Basistherapie und die wichtigsten akuten Behandlungspfade besprochen.

Abstract 35: MR CLEAN Registry: A Post-trial Multicenter Registry of Intra-arterial Treatment for Acute Ischemic Stroke in the Netherlands

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ivo Jansen ◽  
Maxim Mulder ◽  
Robert-Jan Goldhoorn ◽  
Aad van der Lugt ◽  
Henk Marquering ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
The Netherlands ◽  
Acute Ischemic Stroke ◽  
Randomized Clinical Trials ◽  
Infarct Volume ◽  
Primary Study ◽  
Anterior Circulation ◽  
Serious Adverse Events ◽  
Post Trial ◽  
Mr Clean

Background & Purpose: Intra-arterial therapy (IAT) is being implemented worldwide as the main treatment option for acute ischemic stroke (AIS). We wondered whether effectiveness and safety results that have been reported in randomized clinical trials can be reproduced in everyday clinical practice. We will report results of the Dutch National post MR CLEAN IAT registry including work flow parameters, primary and secondary outcomes, as well as serious adverse events. Methods: The MR CLEAN Registry is a prospective registry of all patients undergoing IAT for AIS in the Netherlands, started after completion of the MR CLEAN trial in March 2014. Registration was required for reimbursement. A core set was defined, with inclusion criteria similar to those of the MR CLEAN trial, including a proven anterior circulation occlusion and treatment possible withing 6 hours from onset. The primary study outcome is the score on the modified Rankin Scale (mRS) at 90 days. The secondary clinical outcome is NIHSS after 24 to 48 hours. Secondary radiological outcomes include the mTICI score on DSA and final infarct volume and major bleeding on follow up NCCT. We used a propensity weighted and an unadjusted ordinal logistic regression model to compare outcomes in the MR CLEAN Registry core and total dataset with the treatment arm of MR CLEAN. Results: Between March 2014 and August 2016 the inclusion rate of the MR CLEAN Registry has been increasing steadily to an average of 79 (SD 22) per month for a cumulative inclusion of 1548 patients in July 2016 (Figure 1). Conclusions: The MR CLEAN registry data is now being analyzed. Results will be reported at the conference.

Abstract TP32: Endovascular Therapy for Acute Ischemic Stroke Beyond the 6 Hour Window

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Yi Mao ◽  
Sameer Sharma ◽  
Hesham Masoud ◽  
Julius G Latorre
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Current Data ◽  
Posterior Circulation ◽  
Published Data ◽  
Advanced Imaging ◽  
Poor Outcomes ◽  
Mr Clean ◽  
Insight Into

Background: Recent randomized trials demonstrated the efficacy of endovascular therapy (EVT) in managing acute ischemic stroke (AIS), though EVT was initiated <6 hours from time last seen well in nearly all patients, and posterior circulation strokes were excluded. Current data is limited for patients receiving EVT >6 hours, and more so for those with posterior circulation strokes. We aim to assess safety and clinical outcome of EVT in patients presenting >6 hours, with anterior or posterior circulation strokes. Methods: We conducted a retrospective review of patients with AIS receiving EVT >6 hours between 2012-2015, including those with unknown time of onset and wake-up strokes. Outcomes observed include mRS at ≥90 days, rates of recanalization (TICI 2b-3), sICH and mortality. Results: A total of 34 patients were identified presenting with AIS and receiving EVT >6 hours, including 25 anterior and 9 posterior circulation strokes. See Table 1 for comparison with published data from recent EVT trials. Conclusion: Our results are not significantly different from some of the recent trials. MR CLEAN, the only trial that did not employ advanced imaging in patient selection, had similar outcomes. The IV-tPA only groups of recent trials (where data is available) also produced comparable results. It should be noted that the patients in our study all have large vessel occlusions and high NIHSS, are mostly ineligible for tPA, and thus would be expected to have very poor outcomes without treatment. Our data supports the possibility of expanding the EVT window to >6 hours, and with advanced imaging screening, better rates of functional outcome/mortality may still be achieved. DAWN and DEFUSE3 trials currently underway should provide further insight into this subject.

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

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kars C Compagne ◽  
Manon Kappelhof ◽  
Robert-Jan B Goldhoorn ◽  
Charles B Majoie ◽  
Yvo B Roos ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Practice ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Independence ◽  
Routine Clinical Practice ◽  
Anterior Circulation ◽  
Time To Treatment ◽  
Mr Clean

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.

Balloon Guide Catheter in Endovascular Treatment for Acute Ischemic Stroke: Results from the MR CLEAN Registry

2019 ◽  
Vol 30 (11) ◽  
pp. 1759-1764.e6 ◽  
Author(s):  
Robert-Jan B. Goldhoorn ◽  
Nele Duijsters ◽  
Charles B.L.M. Majoie ◽  
Yvo B.W.E.M. Roos ◽  
Diederik W.J. Dippel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Guide Catheter ◽  
Mr Clean
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