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van der Steen W, van de Graaf RA, Chalos V, Lingsma HF, van Doormaal PJ, Coutinho JM, Emmer BJ, de Ridder I, van Zwam W, van der Worp HB, van der Schaaf I, Gons RAR, Yo LSF, Boiten J, van den Wijngaard I, Hofmeijer J, Martens J, Schonewille W, Vos JA, Tuladhar AM, de Laat KF, van Hasselt B, Remmers M, Vos D, Rozeman A, Elgersma O, Uyttenboogaart M, Bokkers RPH, van Tuijl J, Boukrab I, van den Berg R, Beenen LFM, Roosendaal SD, Postma AA, Krietemeijer M, Lycklama G, Meijer FJA, Hammer S, van der Hoorn A, Yoo AJ, Gerrits D, Truijman MTB, Zinkstok S, Koudstaal PJ, Manschot S, Kerkhoff H, Nieboer D, Berkhemer O, Wolff L, van der Sluijs PM, van Voorst H, Tolhuisen M, Roos YBWEM, Majoie CBLM, Staals J, van Oostenbrugge RJ, Jenniskens SFM, van Dijk LC, den Hertog HM, van Es ACGM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of aspirin, unfractionated heparin, both, or neither during endovascular stroke treatment (MR CLEAN-MED): an open-label, multicentre, randomised controlled trial. Lancet 2022; 399:1059-1069. [PMID: 35240044 DOI: 10.1016/s0140-6736(22)00014-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Aspirin and unfractionated heparin are often used during endovascular stroke treatment to improve reperfusion and outcomes. However, the effects and risks of anti-thrombotics for this indication are unknown. We therefore aimed to assess the safety and efficacy of intravenous aspirin, unfractionated heparin, both, or neither started during endovascular treatment in patients with ischaemic stroke. METHODS We did an open-label, multicentre, randomised controlled trial with a 2 × 3 factorial design in 15 centres in the Netherlands. We enrolled adult patients (ie, ≥18 years) with ischaemic stroke due to an intracranial large-vessel occlusion in the anterior circulation in whom endovascular treatment could be initiated within 6 h of symptom onset. Eligible patients had a score of 2 or more on the National Institutes of Health Stroke Scale, and a CT or MRI ruling out intracranial haemorrhage. Randomisation was done using a web-based procedure with permuted blocks and stratified by centre. Patients were randomly assigned (1:1) to receive either periprocedural intravenous aspirin (300 mg bolus) or no aspirin, and randomly assigned (1:1:1) to receive moderate-dose unfractionated heparin (5000 IU bolus followed by 1250 IU/h for 6 h), low-dose unfractionated heparin (5000 IU bolus followed by 500 IU/h for 6 h), or no unfractionated heparin. The primary outcome was the score on the modified Rankin Scale at 90 days. Symptomatic intracranial haemorrhage was the main safety outcome. Analyses were based on intention to treat, and treatment effects were expressed as odds ratios (ORs) or common ORs, with adjustment for baseline prognostic factors. This trial is registered with the International Standard Randomised Controlled Trial Number, ISRCTN76741621. FINDINGS Between Jan 22, 2018, and Jan 27, 2021, we randomly assigned 663 patients; of whom, 628 (95%) provided deferred consent or died before consent could be asked and were included in the modified intention-to-treat population. On Feb 4, 2021, after unblinding and analysis of the data, the trial steering committee permanently stopped patient recruitment and the trial was stopped for safety concerns. The risk of symptomatic intracranial haemorrhage was higher in patients allocated to receive aspirin than in those not receiving aspirin (43 [14%] of 310 vs 23 [7%] of 318; adjusted OR 1·95 [95% CI 1·13-3·35]) as well as in patients allocated to receive unfractionated heparin than in those not receiving unfractionated heparin (44 [13%] of 332 vs 22 [7%] of 296; 1·98 [1·14-3·46]). Both aspirin (adjusted common OR 0·91 [95% CI 0·69-1·21]) and unfractionated heparin (0·81 [0·61-1·08]) led to a non-significant shift towards worse modified Rankin Scale scores. INTERPRETATION Periprocedural intravenous aspirin and unfractionated heparin during endovascular stroke treatment are both associated with an increased risk of symptomatic intracranial haemorrhage without evidence for a beneficial effect on functional outcome. FUNDING The Collaboration for New Treatments of Acute Stroke consortium, the Brain Foundation Netherlands, the Ministry of Economic Affairs, Stryker, Medtronic, Cerenovus, and the Dutch Heart Foundation.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Bart J Emmer
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Inger de Ridder
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Irene van der Schaaf
- Department of Radiology, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob A R Gons
- Department of Neurology, Catharina Hospital, Eindhoven, Netherlands
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Ido van den Wijngaard
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands; Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | | | - Jasper Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Jan Albert Vos
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Anil Man Tuladhar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Michel Remmers
- Department of Neurology, Amphia Hospital, Breda, Netherlands
| | - Douwe Vos
- Department of Radiology, Amphia Hospital, Breda, Netherlands
| | - Anouk Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Otto Elgersma
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, Netherlands; Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Julia van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Issam Boukrab
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - René van den Berg
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Stefan D Roosendaal
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Alida Annechien Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | - Geert Lycklama
- Department of Radiology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Anouk van der Hoorn
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, Netherlands
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | | | - Martine T B Truijman
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Peter J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sanne Manschot
- Department of Neurology, Haaglanden Medical Centre, The Hague, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Olvert Berkhemer
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Henk van Voorst
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Manon Tolhuisen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Sjoerd F M Jenniskens
- Department of Medical Imaging, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | | | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
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