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

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.

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

2019 ◽  
Vol 11 (9) ◽  
pp. 866-873 ◽  
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.

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.

scholarly journals Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 923-930 ◽  
Author(s):  
Esmee Venema ◽  
Adrien E. Groot ◽  
Hester F. Lingsma ◽  
Wouter Hinsenveld ◽  
Kilian M. Treurniet ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Functional Independence ◽  
Modified Rankin Scale ◽  
Interhospital Transfer ◽  
Primary Stroke Center ◽  
Transferred Patients ◽  
Stroke Center

Background and Purpose— To assess the effect of inter-hospital transfer on time to treatment and functional outcome after endovascular treatment (EVT) for acute ischemic stroke, we compared patients transferred from a primary stroke center to patients directly admitted to an intervention center in a large nationwide registry. Methods— MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, observational study in all centers that perform EVT in the Netherlands. We included adult patients with an acute anterior circulation stroke who received EVT between March 2014 to June 2016. Primary outcome was time from arrival at the first hospital to arterial groin puncture. Secondary outcomes included the 90-day modified Rankin Scale score and functional independence (modified Rankin Scale score of 0–2). Results— In total 821/1526 patients, (54%) were transferred from a primary stroke center. Transferred patients less often had prestroke disability (227/800 [28%] versus 255/699 [36%]; P =0.02) and more often received intravenous thrombolytics (659/819 [81%] versus 511/704 [73%]; P <0.01). Time from first presentation to groin puncture was longer for transferred patients (164 versus 104 minutes; P <0.01, adjusted delay 57 minutes [95% CI, 51–62]). Transferred patients had worse functional outcome (adjusted common OR, 0.75 [95% CI, 0.62–0.90]) and less often achieved functional independence (244/720 [34%] versus 289/681 [42%], absolute risk difference −8.5% [95% CI, −8.7 to −8.3]). Conclusions— Interhospital transfer of patients with acute ischemic stroke is associated with delay of EVT and worse outcomes in routine clinical practice, even in a country where between-center distances are short. Direct transportation of patients potentially eligible for EVT to an intervention center may improve functional outcome.

scholarly journals Outcome Prediction Models for Endovascular Treatment of Ischemic Stroke: Systematic Review and External Validation

Stroke ◽  
2021 ◽  
Author(s):  
Femke Kremers ◽  
Esmee Venema ◽  
Martijne Duvekot ◽  
Lonneke Yo ◽  
Reinoud Bokkers ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
The Netherlands ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Prediction Models ◽  
Predictive Performance ◽  
Data Availability ◽  
Vascular Events ◽  
Discriminative Performance

Background and Purpose: Prediction models for outcome of patients with acute ischemic stroke who will undergo endovascular treatment have been developed to improve patient management. The aim of the current study is to provide an overview of preintervention models for functional outcome after endovascular treatment and to validate these models with data from daily clinical practice. Methods: We systematically searched within Medline, Embase, Cochrane, Web of Science, to include prediction models. Models identified from the search were validated in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, which includes all patients treated with endovascular treatment within 6.5 hours after stroke onset in the Netherlands between March 2014 and November 2017. Predictive performance was evaluated according to discrimination (area under the curve) and calibration (slope and intercept of the calibration curve). Good functional outcome was defined as a score of 0–2 or 0–3 on the modified Rankin Scale depending on the model. Results: After screening 3468 publications, 19 models were included in this validation. Variables included in the models mainly addressed clinical and imaging characteristics at baseline. In the validation cohort of 3156 patients, discriminative performance ranged from 0.61 (SPAN-100 [Stroke Prognostication Using Age and NIH Stroke Scale]) to 0.80 (MR PREDICTS). Best-calibrated models were THRIVE (The Totaled Health Risks in Vascular Events; intercept −0.06 [95% CI, −0.14 to 0.02]; slope 0.84 [95% CI, 0.75–0.95]), THRIVE-c (intercept 0.08 [95% CI, −0.02 to 0.17]; slope 0.71 [95% CI, 0.65–0.77]), Stroke Checkerboard score (intercept −0.05 [95% CI, −0.13 to 0.03]; slope 0.97 [95% CI, 0.88–1.08]), and MR PREDICTS (intercept 0.43 [95% CI, 0.33–0.52]; slope 0.93 [95% CI, 0.85–1.01]). Conclusions: The THRIVE-c score and MR PREDICTS both showed a good combination of discrimination and calibration and were, therefore, superior in predicting functional outcome for patients with ischemic stroke after endovascular treatment within 6.5 hours. Since models used different predictors and several models had relatively good predictive performance, the decision on which model to use in practice may also depend on simplicity of the model, data availability, and the comparability of the population and setting.

scholarly journals Combined Effect of Age and Baseline Alberta Stroke Program Early Computed Tomography Score on Post-Thrombectomy Clinical Outcomes in the MR CLEAN Registry

Stroke ◽  
2020 ◽  
Vol 51 (12) ◽  
pp. 3742-3745
Author(s):  
Johanna Ospel ◽  
Manon Kappelhof ◽  
Adrien E. Groot ◽  
Natalie E. LeCouffe ◽  
Jonathan M. Coutinho ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Modified Rankin Scale ◽  
Common Odds Ratio ◽  
Significant Difference ◽  
Main Effect ◽  
Mr Clean

Background and Purpose: Ischemic brain tissue damage in patients with acute ischemic stroke, as measured by the Alberta Stroke Program Early CT Score (ASPECTS) may be more impactful in older than in younger patients, although this has not been studied. We aimed to investigate a possible interaction effect between age and ASPECTS on functional outcome in acute ischemic stroke patients undergoing endovascular treatment, and compared reperfusion benefit across age and ASPECTS subgroups. Methods: Patients with ischemic stroke from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; March 2014–November 2017) were included. Multivariable ordinal logistic regression was performed to obtain effect size estimates (adjusted common odds ratio) on functional outcome (modified Rankin Scale score) for continuous age and granular ASPECTS, with a 2-way multiplicative interaction term (age×ASPECTS). Outcomes in four patient subgroups based on age (< versus ≥ median age [71.8 years]) and baseline ASPECTS (6–10 versus 0–5) were assessed. Results: We included 3279 patients. There was no interaction between age and ASPECTS on modified Rankin Scale ( P =0.925). The highest proportion of modified Rankin Scale 5 to 6 was observed in patients >71.8 years with baseline ASPECTS 0 to 5 (68/107, 63.6%). There was benefit of reperfusion in all age-ASPECTS subgroups. Although the adjusted common odds ratio was lower in patients >71.8 years with ASPECTS 0 to 5 (adjusted common odds ratio, 1.60 [95% CI, 0.66–3.88], n=110), there was no significant difference from the main effect ( P =0.299). Conclusions: Although the proportion of poor outcomes following endovascular treatment was highest in older patients with low baseline ASPECTS, outcomes did not significantly differ from the main effect. These results do not support withholding endovascular treatment based n a combination of high age and low ASPECTS.

Sign in / Sign up

Export Citation Format

Share Document