Effect of Workflow Improvements on Time to Endovascular Thrombectomy for Acute Ischemic Stroke in the MR CLEAN Registry

You absolute blithering idiots! You're not measuring or even trying for 100% recovery! When you are the 1 in 4 per WHO that has a stroke you'll want 100% recovery. So why aren't you trying for that goal now?

Laziness? Incompetence? Or just don't care? No leadership? NO strategy? Not my job? Not my Problem?

Effect of Workflow Improvements on Time to Endovascular Thrombectomy for Acute Ischemic Stroke in the MR CLEAN Registry

Paula M. Janssen,

Bob Roozenbeek,

Jonathan M. Coutinho,

Adriaan C.G.M. van Es,

Wouter J. Schonewille,

Geert J. Lycklama a Nijeholt,

Hester F. Lingsma,

… See all authors

Originally published27 Apr 2023https://doi.org/10.1161/SVIN.122.000733Stroke: Vascular and Interventional Neurology. 2023;3:e000733

• Other version(s) of this article

Abstract

Background

Insight in the effect of workflow improvements can help to minimize the time between onset of ischemic stroke and start of endovascular thrombectomy (EVT). The authors aimed to assess the implementation of EVT workflow strategies and their effect on time to treatment.

Methods

The authors used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) registry and included patients with acute ischemic stroke in the anterior circulation, who underwent EVT between March 2014 and November 2017. Data on implementation of 20 predefined workflow improvement strategies during the study period were collected from each intervention center. Multilevel linear regression with a random intercept for center was used to quantify the effect of each strategy on door‐to‐groin puncture time, with adjustment for calendar time, for directly presented and transferred patients separately.

Results

The authors included 2633 patients who were treated in 14 intervention centers. Of the 20 predefined strategies, 18 were actually implemented in ≥1 centers during the study period. In directly presented patients (n=1157), the intervention with the largest effect on door‐to‐groin puncture time was a strategy to avoid sedation during EVT compared with standard use of general anesthesia, which led to a reduction of 29% (95% CI, 6–46; P=0.02), corresponding to a decrease of 26 minutes (95% CI, 5–42). In transferred patients (n=1476), the interventions with the largest decrease in door‐to‐groin puncture time were a strategy to make the decision for patient transfer to the angiosuite after 1 stroke physician assessed the imaging, instead of both interventionist and neurologist (47% [95% CI, 5–70]; 19 minutes [95% CI, 2–29]) (P=0.03), and a strategy to perform neurological assessment at the angiosuite instead of the emergency department (32% [95% CI, 19–43]; 13 minutes [95% CI, 8–17]) (P<0.001).

Conclusion

Intervention centers have implemented multiple new strategies to improve their workflow. Such workflow improvements lead to substantial reductions in time to EVT and may thereby improve the outcome of patients with acute ischemic stroke.

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Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Your doctor is responsible for fixing brain atrophy post stroke and has had years to come up with  a solution. Was s/he incompetent in not solving that problem?

With your brain atrophy post stroke you'll have to ask your doctor about this. 

 What is your doctor's protocol to prevent both brain and muscle atrophy?  No protocol, call the president and ask when competent persons will be hired.

• brain atrophy (11 posts to July 2015)

• cerebral atrophy (2 posts to April 2016)

• Cortical atrophy (1 post to February 2019)
  

• Frontal Cortical Atrophy (1 post to June 2016)

• hippocampal atrophy (1 post to October 2019)

  The latest here:

Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Sven PR Luijten,¹ Kars CJ Compagne,¹ Adriaan CGM van Es,² Yvo BWEM Roos,³ Charles BLM Majoie,⁴ Robert J van Oostenbrugge,⁵ Wim H van Zwam,⁶ Diederik WJ Dippel,⁷ Frank J Wolters,^1,8 Aad van der Lugt,¹ and Daniel Bos^1,8, on behalf of the MR CLEAN trial investigators

Author information Article notes Copyright and License information PMC Disclaimer

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Supplementary Materials

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Abstract

Background

Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion.

Methods

We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 − TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation.

Results

We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97–3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03–3.74] in the middle tertile vs. 3.15 [95% CI: 1.59–6.24] in the highest tertile).

Conclusion

Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.

Keywords: Ischemic stroke, acute stroke therapy, CT scan

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Introduction

Benefit of endovascular treatment (EVT) for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior cerebral circulation has been demonstrated among a diverse variety of patient subgroups including older adults over age 80. ¹ This group currently makes up 25% of the stroke population receiving EVT in daily clinical practice. ² In these patients, brain atrophy is a common finding on diagnostic stroke imaging at hospital admission. ³ Whether brain atrophy influences the effect of EVT, however, is undetermined.

Previous studies showed that in patients receiving EVT brain atrophy is independently associated with poor functional outcome,^4,5 but modification of the effect of EVT by brain atrophy in clinical controlled trials has not been reported. Given that the age distribution of EVT-eligible patients is shifting towards older ages^2,6 and will continue to do so over the next years due to aging of the population,^7,8 atrophy will be encountered more frequently.^9,10 This may be relevant for optimizing patient selection as brain atrophy may provide more individualized estimates of expected treatment benefit and clinical outcome as opposed to age.

Therefore, we investigated whether brain atrophy modifies the effect of EVT in patients with AIS due to LVO, and particularly, whether treatment benefit is uniform across the entire range of brain atrophy.

More at link.

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

This is what is so wrong with stroke research. Using reperfusion as the endpoint rather than 100% recovery. No measurement of 100% recovery. Bad research, the mentors and senior researchers need to be fired. 

“What's measured, improves.” So said management legend and author Peter F. Drucker 

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

Kars C.J. Compagne

,

Manon Kappelhof

,

Wouter H. Hinsenveld

,

Josje Brouwer

,

Robert-Jan B. Goldhoorn

,

Maarten Uyttenboogaart

,

Reinoud P.H. Bokkers

,

Wouter J. Schonewille

,

Jasper M. Martens

,

Jeannette Hofmeijer

… See all authors

and on behalf of the MR CLEAN Registry Investigators

Originally published9 Feb 2022https://doi.org/10.1161/STROKEAHA.121.034919Stroke. 2022;53:1863–1872

• Other version(s) of this article

Abstract

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 endovascular treatment for acute ischemic stroke in routine clinical practice have improved over the past years, likely resulting from improved workflow times and higher successful reperfusion rates.

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Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Useless, you tell us NOTHING on how to stop brain atrophy.  Stroke survivors just might want a solution for that. Will you think for once?

Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial

Sven Pr Luijten, Kars Cj Compagne, Adriaan Cgm van Es, Yvo Bwem Roos

BACKGROUND 

Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion.

METHODS 

We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation.

RESULTS 

We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74]in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile).

CONCLUSION 

 Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.

Source: International Journal of Stroke

 

Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry

Damn it all, survivors don't give a flying fuck about successful reperfusion, that is only an intermediate step on the way to full recovery.  You're declaring victory  on the first lap of a 500 lap race when the survivor is nowhere close to recovery.

Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry

1. http://orcid.org/0000-0002-1043-1125Faysal Benali1,2,
2. http://orcid.org/0000-0001-5250-8955Manon Kappelhof3,
3. Johanna Ospel4,
4. http://orcid.org/0000-0001-5520-2070Aravind Ganesh2,
5. Rosalie V McDonough2,5,
6. Alida A Postma1,
7. http://orcid.org/0000-0002-0062-2614Robert-Jan Berend Goldhoorn6,
8. Charles B L M Majoie3,
9. Ido van den Wijngaard7,
10. Hester F Lingsma8,
11. Jan Albert Vos9,
12. Robert J van Oostenbrugge6,
13. http://orcid.org/0000-0003-1631-7056Wim H van Zwam1,
14. http://orcid.org/0000-0001-9060-2109Mayank Goyal2
15. on behalf of MR CLEAN Registry investigators

1. Correspondence to Dr Mayank Goyal, Diagnostic Imaging, University of Calgary, Calgary, AB T2N 1N4, Canada; mgoyal2412@gmail.com

Abstract

Background Pre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence exists for EVT in those patients. We aimed to investigate the safety and benefit of EVT in pre-stroke patients with mRS score 3.

Methods We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in the Netherlands (MR CLEAN) Registry. All patients treated with EVT for anterior circulation AIS with pre-stroke mRS 3 were included. We assessed causes for dependence and compared patients with successful reperfusion (defined as expanded Thrombolysis in Cerebral Ischemia scale (eTICI) 2b–3) to patients without successful reperfusion. We used regression analyses with pre-specified adjustments. Our primary outcome was 90-day mRS 0–3 (functional improvement or return to baseline).

Results A total of 192 patients were included, of whom 82 (43%) had eTICI <2b and 108 (56%) eTICI ≥2b. The median age was 80 years (IQR 73–87). Fifty-one of the 192 patients (27%) suffered from previous stroke and 36/192 (19%) had cardiopulmonary disease. Patients with eTICI ≥2b more often returned to their baseline functional state or improved (n=26 (26%) vs n=15 (19%); adjusted odds ratio (aOR) 2.91 (95% CI 1.08 to 7.82)) and had lower mortality rates (n=49 (49%) vs n=50 (64%); aOR 0.42 (95% CI 0.19 to 0.93)) compared with patients with eTICI <2b.

Conclusions Although patients with AIS with pre-stroke mRS 3 comprise a heterogenous group of disability causes, we observed improved outcomes when patients achieved successful reperfusion after EVT.

Data availability statement

Data are available upon reasonable request.

http://dx.doi.org/10.1136/neurintsurg-2022-018853

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Data availability statement

Data are available upon reasonable request.

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Footnotes

• Twitter @draravindganesh, @rosevmcd

• Collaborators 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

• Contributors FB collected and analyzed the data and wrote the manuscript. MK analyzed the data and revised the manuscript. JO, AG and RVM revised the manuscript. MG and WHvZ created the hypothesis and research question. All co-authors assisted in revising the manuscript. MG is the guarantor.

• Funding The MR CLEAN Registry was supported by a grant from the Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN).

• Competing interests WHvZ: Speaker fees from Stryker, Cerenovus, NicoLab (all paid to institution). MG: consultant (Medtronic, Stryker, Mentice, Microvention), license agreement (GE Healthcare, Microvention). AG: reports membership of editorial boards of Neurology, Neurology: Clinical Practice, and Stroke; research support from the Canadian Institutes of Health Research, Canadian Cardiovascular Society, Campus Alberta Neuroscience, and Alberta Innovates; consultation fees from MD Analytics, CTC Communications Corp, MyMedicalPanel, and Atheneum; stock options from SnapDx, TheRounds.com, and Advanced Health Analytics (AHA Health Ltd); and a provisional patent application for a system for delivery of remote ischemic conditioning or other cuff-based therapies. JO: consultant (NICO.Lab). CBLM: grants from TWIN Foundation during the conduct of the study (paid to institution); grants from CVON/Dutch Heart Foundation, grants from European Commission, grants from Health Evaluation Netherlands, grants from Stryker outside the submitted work (paid to institution); and is a shareholder of Nico-lab.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Predictors of poor outcome despite successful endovascular treatment for ischemic stroke: results from the MR CLEAN Registry

You blithering idiots, the stroke medical world has accepted these failures since the beginning of time and passed them of as success by bamboozling everyone into accepting their tyranny of low expectations.

Hope they are OK with that shitworthy result when they are the 1 in 4 per WHO that has a stroke?

 

 Predictors of poor outcome despite successful endovascular treatment for ischemic stroke: results from the MR CLEAN Registry

1. Rob A van de Graaf1,2,
2. Noor Samuels1,2,3,
3. Vicky Chalos1,2,3,
4. Geert J Lycklama a Nijeholt4,
5. Heleen van Beusekom5,
6. Albert J Yoo6,
7. http://orcid.org/0000-0003-1631-7056Wim H van Zwam7,
8. Charles B L M Majoie8,
9. Yvo B W E M Roos9,
10. Pieter Jan van Doormaal1,
11. Wagih Ben Hassen10,
12. Aad van der Lugt1,
13. http://orcid.org/0000-0002-9234-3515Diederik W J Dippel2,
14. Hester F Lingsma3,
15. Adriaan C G M van Es11,
16. Bob Roozenbeek1,2
17. MR CLEAN Registry investigators

1. Correspondence to Rob A van de Graaf, Radiology & Nuclear Medicine and Neurology, Erasmus Medical Center, 3015 GD Rotterdam, Zuid-Holland, The Netherlands; r.a.vandegraaf@erasmusmc.nl

Abstract

Background Approximately one-third of patients with ischemic stroke treated with endovascular treatment do not recover to functional independence despite rapid and successful(It wasn't successful if you didn't get to 100% recovery.) recanalization. We aimed to quantify the >/u> importance of predictors of poor functional outcome despite successful reperfusion.

Methods We analyzed patients from the MR CLEAN Registry between March 2014 and November 2017 with successful reperfusion (extended Thrombolysis In Cerebral Infarction ≥2B). First, predictors were selected based on expert opinion and were clustered according to acquisition over time (ie, baseline patient factors, imaging factors, treatment factors, and postprocedural factors). Second, several models were constructed to predict 90-day functional outcome (modified Rankin Scale (mRS)). The relative importance of individual predictors in the most extensive model was expressed by the proportion of unique added χ² to the model of that individual predictor.

Results Of 3180 patients, 1913 (60%) had successful reperfusion. Of these 1913 patients, 1046 (55%) were functionally dependent at 90 days (mRS >2). The most important predictors for mRS were baseline patient factors (ie, pre-stroke mRS, added χ² 0.16; National Institutes of Health Stroke Scale score at baseline, added χ² 0.12; age, added χ² 0.10), and postprocedural factors (ie, symptomatic intracranial hemorrhage (sICH), added χ² 0.12; pneumonia, added χ² 0.09). The probability of functional independence for a typical stroke patient with sICH was 54% (95% CI 36% to 72%) lower compared with no sICH, and 21% (95% CI 4% to 38%) for pneumonia compared with no pneumonia.

Conclusion Baseline patient factors and postprocedural adverse events are important predictors of poor functional outcome in successfully reperfused patients with ischemic stroke. This implies that prevention of postprocedural adverse events has the greatest potential to further improve outcomes in these patients.

Data availability statement

No data are available. Data cannot be made available, as no patient approval has been obtained for sharing coded data. However, R syntax and output files of the analyses will be made available on request.

http://dx.doi.org/10.1136/neurintsurg-2021-017726

 

Prediction of Outcome and Endovascular Treatment Benefit: Validation and Update of the MR PREDICTS Decision Tool

 So immediately upon receiving this information our stroke leaders should initiate research so such poor outcomes don't occur. BUT WE HAVE NO STROKE LEADERSHIP.

Prediction of Outcome and Endovascular Treatment Benefit: Validation and Update of the MR PREDICTS Decision Tool

Esmee Venema

,

Bob Roozenbeek

,

Maxim J.H.L. Mulder

,

Scott Brown

,

Charles B.L.M. Majoie

,

Ewout W. Steyerberg

,

Andrew M. Demchuk

,

Keith W. Muir

,

Antoni Dávalos

,

Peter J. Mitchell

, … See all authors

and on behalf of the HERMES collaborators and MR CLEAN Registry Investigators

Originally published16 Jul 2021https://doi.org/10.1161/STROKEAHA.120.032935Stroke. ;0:STROKEAHA.120.032935

Abstract

Background and Purpose:

Benefit of early endovascular treatment (EVT) for ischemic stroke varies considerably among patients.(It shouldn't, that's what objective diagnosis leading to EXACT STROKE PROTOCOLS would resolve.)  The MR PREDICTS decision tool, derived from MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), predicts outcome and treatment benefit based on baseline characteristics. Our aim was to externally validate and update MR PREDICTS with data from international trials and daily clinical practice.

Methods:

We used individual patient data from 6 randomized controlled trials within the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration to validate the original model. Then, we updated the model and performed a second validation with data from the observational MR CLEAN Registry. Primary outcome was functional independence (defined as modified Rankin Scale score 0–2) 3 months after stroke. Treatment benefit was defined as the difference between the probability of functional independence with and without EVT. Discriminative performance was evaluated using a concordance (C) statistic.

Results:

We included 1242 patients from HERMES (633 assigned to EVT, 609 assigned to control) and 3156 patients from the MR CLEAN Registry (all of whom underwent EVT within 6.5 hours). The C-statistic for functional independence was 0.74 (95% CI, 0.72–0.77) in HERMES and, after model updating, 0.80 (0.78–0.82) in the Registry. Median predicted treatment benefit of routinely treated patients (Registry) was 10.3% (interquartile range, 5.8%–14.4%). Patients with low (<1%) predicted treatment benefit (n=135/3156 [4.3%]) had low rates of functional independence, irrespective of reperfusion status, suggesting potential absence of treatment benefit(You are to leave no survivor behind! At least competent medical professionals wouldn't.They would initiate research to solve those problems.). The updated model was made available online for clinicians and researchers at www.mrpredicts.com.

Conclusions:

Because of the substantial treatment effect and small potential harm of EVT, most patients arriving within 6 hours at an endovascular-capable center should be treated regardless of their clinical characteristics. MR PREDICTS can be used to support clinical judgement when there is uncertainty about the treatment indication, when resources are limited, or before a patient is to be transferred to an endovascular-capable center.

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Prior antiplatelet therapy in patients undergoing endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry

In plain words I have no fucking clue what this means.

Prior antiplatelet therapy in patients undergoing endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry

Show all authors

Rob A van de Graaf, Sanne M Zinkstok, Vicky Chalos, ...

First Published August 14, 2020 Research Article Find in PubMed 

https://doi.org/10.1177/1747493020946975

Article information

   

Abstract

Background

Antiplatelet therapy may increase the risk of symptomatic intracranial hemorrhage after endovascular treatment for ischemic stroke but may also have a beneficial effect on functional outcome. The aim of this study is to compare safety and efficacy outcomes after endovascular treatment in patients with and without prior antiplatelet therapy.

Methods

We analyzed patients registered in the MR CLEAN Registry between March 2014 and November 2017, for whom data on antiplatelet therapy were available. We used propensity score nearest-neighbor matching with replacement to balance the probability of receiving prior antiplatelet therapy between the prior antiplatelet therapy and no prior antiplatelet therapy group and adjusted for baseline prognostic factors to compare these groups. Primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes were 90-day functional outcome (modified Rankin Scale), successful reperfusion (extended thrombolysis in cerebral infarction score ≥2B) and 90-day mortality.

Results

Thirty percent (n = 937) of the 3154 patients were on prior antiplatelet therapy, who were matched to 477 patients not on prior antiplatelet therapy. Symptomatic intracranial hemorrhage occurred in 74/937 (7.9%) patients on prior antiplatelet therapy and in 27/477 (5.6%) patients without prior antiplatelet therapy adjusted odds ratio 1.47, 95% confidence interval 0.86–2.49. No associations were found between prior antiplatelet therapy and functional outcome (adjusted common odds ratio 0.87, 95% confidence interval 0.65–1.16), successful reperfusion (adjusted odds ratio 1.23, 95% confidence interval 0.77–1.97), or 90-day mortality (adjusted odds ratio 1.15, 95% confidence interval 0.86–1.54).

Conclusion

We found no evidence of an association of prior antiplatelet therapy with the risk of symptomatic intracranial hemorrhage after endovascular treatment, nor on functional outcome, reperfusion, or mortality. A substantial beneficial or detrimental effect of antiplatelet therapy on clinical outcome cannot be excluded. A randomized clinical trial comparing antiplatelet therapy versus no antiplatelet therapy is needed.

Keywords Antiplatelet, endovascular, MR CLEAN Registry, thrombectomy, stroke

Introduction

Approximately 50% of patients with ischemic stroke do not recover to functional independence after endovascular treatment (EVT).¹ (That is absolutely appalling. What is your solution to change that to 100% recovery?)Although pre-stroke disability and large baseline infarct core are known causes of these poor outcomes, incomplete microvascular reperfusion—a potentially reversible process—might contribute to these poor outcomes as well. One of the causes of incomplete microvascular reperfusion is the formation of microthrombi occluding the distal capillary bed. These microthrombi are abundantly present after focal cerebral ischemia in the distal vascular territory. The formation of microthrombi might be promoted by vessel wall damage caused by EVT.^2,3 Use of antiplatelet drugs could potentially reduce periprocedural formation of microthrombi by inhibiting platelet aggregation and inflammation of the vessel wall, which could ultimately improve microvascular reperfusion.³ On the other hand, one randomized trial showed that antiplatelet therapy increases the risk of symptomatic intracranial hemorrhage (sICH) when administered early—within 90 min—after intravenous treatment with alteplase.⁴ However, this trial did not focus on the subpopulation of patients with ischemic stroke caused by a large vessel occlusion undergoing EVT. In these patients, the beneficial effect of platelet inhibition could counterbalance the detrimental effects of increase risk of sICH. As interventionists are familiar with periprocedural use of antiplatelet agents during non-stroke neurovascular procedures (i.e. stenting), this treatment might be an easily applicable therapy of adjunctive value in EVT for stroke. However, as antiplatelet agents are not administered systematically during EVT for acute ischemic stroke and current evidence is limited to small observational studies investigating the association of prior antiplatelet therapy with sICH risk and functional outcomes, there are conflicting results.⁵ The evaluation of risks and benefits of prior antiplatelet therapy in a large cohort of patients treated with EVT could provide useful information for clinical practice. The aim of this study is to compare safety and efficacy outcomes, after EVT of patients with and without prior antiplatelet therapy.

 

Association of Reperfusion With Brain Edema in Patients With Acute Ischemic Stroke: A Secondary Analysis of the MR CLEAN Trial

No clue in understanding this. 
https://www.docguide.com/association-reperfusion-brain-edema-patients-acute-ischemic-stroke-secondary-analysis-mr-clean-trial?

Kimberly W, Dutra B, Boers A, Alves H, Berkhemer O, van den Berg L, Sheth K, Roos Y, van der Lugt A, Beenen L, Dippel D, van Zwam W, van Oostenbrugge R, Lingsma H, Marquering H, Majoie C, MR CLEAN Investigators ; JAMA Neurology (Jan 2018)

Tags:

• Stroke

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Importance It is uncertain whether therapeutic reperfusion with endovascular treatment yields more or less brain edema.

Objective To elucidate the association between reperfusion and brain edema. The secondary objectives were to evaluate whether brain edema could partially be responsible for worse outcomes in patients with later reperfusion or lower Alberta Stroke Program Early Computed Tomography Score.

Design, Setting, and Participants This was a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), which was a prospective, randomized, multicenter clinical trial of endovascular treatment compared with conventional care of patients with acute anterior circulation ischemic stroke. Of 502 patients enrolled from December 2010 to June 2014, 2 patients declined to participate. Additionally, exclusion criteria were absence of follow-up imaging or presence of parenchymal hematoma, resulting in 462 patients included in this study. Brain edema was assessed retrospectively, from December 10, 2016, to July 24, 2017, by measuring midline shift (MLS) in all available follow-up scans. Observers were blinded to clinical data.

Main Outcomes and Measures Midline shift was assessed as present or absent and as a continuous variable. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction score in the endovascular treatment arm. The modified arterial occlusive lesion score was used to evaluate the recanalization status in both arms. The modified Rankin scale score at 90 days was used for functional outcome.

Results Of 462 patients, the mean (SD) age was 65 (11) years, and 41.8% (n = 193) were women. Successful reperfusion and recanalization were associated with a reduced likelihood of having MLS (adjusted common odds ratio, 0.25; 95% CI, 0.12-0.53; P < .001 and adjusted common odds ratio, 0.34; 95% CI, 0.21-0.55; P < .001, respectively). Midline shift was partially responsible for worse modified Rankin scale scores in patients without reperfusion or recanalization (MLS changed the logistic regression coefficients by 30.3% and 12.6%, respectively). In patients with delayed reperfusion or lower Alberta Stroke Program Early Computed Tomography Score, MLS mediated part of the worse modified Rankin scale scores, corresponding to a change in the regression coefficient of 33.3% and 64.2%, respectively.

Conclusions and Relevance Successful reperfusion was associated with reduced MLS. This study identifies an additional benefit of reperfusion in relation to edema, as well as rescuing ischemic brain tissue at risk for infarction.

Trial Registration Netherlands Trial Registry number: NTR1804 and Current Controlled Trials number: ISRCTN10888758.

Impact Slides: MR CLEAN to SWIFT-PRIME With Patrick Lyden, MD

More 'happy talk' and still not acknowledging that ER stroke interventions successfully reverse stroke a miniscule number of times.
Medium f*cking whoopee.

http://www.medpagetoday.com/Cardiology/Strokes/52214?
What are the key points from the recent spate of positive trials for mechanical thrombectomy for certain large-vessel ischemic strokes? Patrick D. Lyden, MD, explores the significance of MR CLEAN, SWIFT-PRIME, and other randomized trials.
Lyden serves as chair of the department of neurology and director of the stroke program at Cedars-Sinai Medical Center in Los Angeles. He was an investigator on the key tissue plasminogen activator (tPA) trial in the mid-1990s and remains on the editorial boards of Stroke, the International Journal of Stroke, and the Journal of Stroke and Cerebrovascular Disease.

3:36 minutes of video explanation.