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Hund HM, Boodt N, Hansen D, Haffmans WA, Lycklama À Nijeholt GJ, Hofmeijer J, Dippel DWJ, van der Lugt A, van Es ACGM, van Beusekom HMM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Boiten J, Vos JA, Jansen IGH, Mulder MJHL, Goldhoorn RJB, Compagne KCJ, Kappelhof M, Brouwer J, den Hartog SJ, Hinsenveld WH, Roozenbeek B, Emmer BJ, Coutinho JM, Schonewille WJ, Wermer MJH, van Walderveen MAA, Staals J, Martens JM, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PLM, van Tuijl J, Peluso JP, Fransen P, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RPH, Schreuder THCML, Heijboer RJJ, Keizer K, Yo LSF, den Hertog HM, Bulut T, Brouwers PJAM, Sprengers MES, Jenniskens SFM, van den Berg R, Yoo AJ, Beenen LFM, Postma AA, Roosendaal SD, van der Kallen BFW, van den Wijngaard IR, Bot J, van Doormaal PJ, Meijer A, Ghariq E, van Proosdij MP, Krietemeijer GM, Dinkelaar W, Appelman APA, Hammer B, Pegge S, van der Hoorn A, Vinke S, Flach HZ, Lingsma HF, el Ghannouti N, Sterrenberg M, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Aaldering N, Zweedijk B, Vervoort J, Ponjee E, Romviel S, Kanselaar K, Barning D, Venema E, Chalos V, Geuskens RR, van Straaten T, Ergezen S, Harmsma RRM, Muijres D, de Jong A, Berkhemer OA, Boers AMM, Huguet J, Groot PFC, Mens MA, van Kranendonk KR, Treurniet KM, Tolhuisen ML, Alves H, Weterings AJ, Kirkels EL, Voogd EJHF, Schupp LM, Collette SL, Groot AED, LeCouffe NE, Konduri PR, Prasetya H, Arrarte-Terreros N, Ramos LA. Association between thrombus composition and stroke etiology in the MR CLEAN Registry biobank. Neuroradiology 2023; 65:933-943. [PMID: 36695859 PMCID: PMC10105654 DOI: 10.1007/s00234-023-03115-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023]
Abstract
PURPOSE The composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice. METHODS The thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification. RESULTS The thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00-1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00-1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar. CONCLUSION Thrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin.
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Affiliation(s)
- Hajo M Hund
- Department of Cardiology, Erasmus MC University Medical Center, Room EE23.93, PO 2040, 3000CA, Rotterdam, The Netherlands.,Department of Radiology, Haaglanden Medical Centrum, The Hague, The Netherlands
| | - Nikki Boodt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Daniel Hansen
- Department of Cardiology, Erasmus MC University Medical Center, Room EE23.93, PO 2040, 3000CA, Rotterdam, The Netherlands
| | - Willem A Haffmans
- Department of Cardiology, Erasmus MC University Medical Center, Room EE23.93, PO 2040, 3000CA, Rotterdam, The Netherlands
| | | | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Heleen M M van Beusekom
- Department of Cardiology, Erasmus MC University Medical Center, Room EE23.93, PO 2040, 3000CA, Rotterdam, The Netherlands.
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van der Steen W, van der Ende NA, van Kranendonk KR, Chalos V, van Oostenbrugge RJ, van Zwam WH, Roos YB, van Doormaal PJ, van Es AC, Lingsma HF, Majoie CB, van der Lugt A, Dippel DW, Roozenbeek B, Boiten J, Albert Vos J, Jansen IG, Mulder MJ, Goldhoorn RJB, Compagne KC, Kappelhof M, Brouwer J, den Hartog SJ, Emmer BJ, Coutinho JM, Schonewille WJ, Albert Vos J, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PL, van Tuijl J, Peluso JP, Fransen P, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RP, Schreuder TH, Heijboer RJ, Keizer K, Yo LS, den Hertog HM, Bulut T, Brouwers PJ, Lycklama GJ, van Walderveen MA, Sprengers ME, Jenniskens SF, van den Berg R, Yoo AJ, Beenen LF, Postma AA, Roosendaal SD, van der Kallen BF, van den Wijngaard IR, Emmer BJ, Martens JM, Yo LS, Vos JA, Bot J, Meijer A, Ghariq E, Bokkers RP, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Dinkelaar W, Auke P, Hammer B, Pegge S, van der Hoorn A, Vinke S, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Hofmeijer J, Martens JM, van der Worp HB, Hofmeijer J, Flach HZ, el Ghannouti N, Sterrenberg M, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Aaldering N, Zweedijk B, Vervoort J, Ponjee E, Romviel S, Kanselaar K, Barning D, Venema E, Geuskens RR, van Straaten T, Ergezen S, Harmsma RR, Muijres D, de Jong A, Berkhemer OA, Boers AM, Huguet J, Groot P, Mens MA, Treurniet KM, Tolhuisen ML, Alves H, Weterings AJ, Kirkels EL, Voogd EJ, Schupp LM, Collette SL, Groot AE, LeCouffe NE, Konduri PR, Prasetya H, Arrarte- Terreros N, Ramos LA, Brown MM, Liebig T, van der Heijden E, Ghannouti N, Fleitour N, Hooijenga I, Puppels C, Pellikaan W, Geerling A, Lindl-Velema A, van Vemde G, de Ridder A, Greebe P, de Bont- Stikkelbroeck J, de Meris J, Haaglanden MC, Janssen K, Licher S, Boodt N, Ros A, Venema E, Slokkers I, Ganpat RJ, Mulder M, Saiedie N, Heshmatollah A, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens RR, Sales Barros R. Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study. Stroke 2022; 53:2818-2827. [PMID: 35674042 PMCID: PMC9389940 DOI: 10.1161/strokeaha.121.036195] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nadinda A.M. van der Ende
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Katinka R. van Kranendonk
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Vicky Chalos
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robert J. van Oostenbrugge
- Amsterdam University Medical Center, University of Amsterdam, the Netherlands. Department of Neurology (R.J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | - Yvo B.W.E.M. Roos
- Department of Neurology (Y.B.W.E.M.R.), Maastricht University Medical Center, the Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C.G.M. van Es
- Department of Radiology, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Hester F. Lingsma
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Charles B.L.M. Majoie
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Amini M, van Leeuwen N, Eijkenaar F, van de Graaf R, Samuels N, van Oostenbrugge R, van den Wijngaard IR, van Doormaal PJ, Roos YBWEM, Majoie C, Roozenbeek B, Dippel D, Burke J, Lingsma HF, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Boiten J, Vos JA, Brouwer J, den Hartog SJ, Hinsenveld WH, Kappelhof M, Compagne KCJ, Goldhoorn RJB, Mulder MJHL, Jansen IGH, Dippel DWJ, Roozenbeek B, van der Lugt A, van Es ACGM, Majoie CBLM, Roos YBWEM, Emmer BJ, Coutinho JM, Schonewille WJ, Vos JA, Wermer MJH, van Walderveen MAA, Staals J, van Oostenbrugge RJ, van Zwam WH, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PLM, van Tuijl J, Peluso JJP, Fransen P, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RPH, Schreuder THCML, Heijboer RJJ, Keizer K, Yo LSF, den Hertog HM, Sturm EJC, Brouwers P, Majoie CBLM, van Zwam WH, van der Lugt A, Lycklama à Nijeholt GJ, van Walderveen MAA, Sprengers MES, Jenniskens SFM, van den Berg R, Yoo AJ, Beenen LFM, Postma AA, Roosendaal SD, van der Kallen BFW, van den Wijngaard IR, van Es ACGM, Emmer BJ, Martens JM, Yo LSF, Vos JA, Bot J, van Doormaal PJ, Meijer A, Ghariq E, Bokkers RPH, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Gerrits D, Dinkelaar W, Appelman APA, Hammer B, Pegge S, van der Hoorn A, Vinke S, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Schonewille WJ, Hofmeijer J, Martens JM, van der Worp HB, Lo RH, van Oostenbrugge RJ, Hofmeijer J, Flach HZ, Lingsma HF, el Ghannouti N, Sterrenberg M, Puppels C, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, van Rijswijk C, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Elfrink M, Aaldering N, Zweedijk B, Khalilzada M, Vervoort J, Droste H, Nicolaij N, Simons M, Ponjee E, Romviel S, Kanselaar K, Bos E, Barning D, Venema E, Chalos V, Geuskens RR, van Straaten T, Ergezen S, Harmsma RRM, Muijres D, de Jong A, Berkhemer OA, Boers AMM, Huguet J, Groot PFC, Mens MA, van Kranendonk KR, Treurniet KM, Jansen IGH, Tolhuisen ML, Alves H, Weterings AJ, Kirkels ELF, Voogd EJHF, Schupp LM, Collette S, Groot AED, LeCouffe NE, Konduri PR, Prasetya H, Arrarte-Terreros N, Ramos LA. Estimation of treatment effects in observational stroke care data: comparison of statistical approaches. BMC Med Res Methodol 2022; 22:103. [PMID: 35399057 PMCID: PMC8996562 DOI: 10.1186/s12874-022-01590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data.
Patients and methods
We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions – i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT – on good functional outcome (modified Rankin Scale ≤2) were estimated. We used three statistical regression-based approaches that vary in assumptions regarding the source of unmeasured confounding: individual-level (two subtypes), ecological, and instrumental variable analyses. In the latter, the preference for using the interventions in each hospital was used as an instrument.
Results
Use of IVT (range 66–87%) and GA (range 0–93%) varied substantially between hospitals. For IVT, the individual-level (OR ~ 1.33) resulted in significant positive effect estimates whereas in instrumental variable analysis no significant treatment effect was found (OR 1.11; 95% CI 0.58–1.56). The ecological analysis indicated no statistically significant different likelihood (β = − 0.002%; P = 0.99) of good functional outcome at hospitals using IVT 1% more frequently. For GA, we found non-significant opposite directions of points estimates the treatment effect in the individual-level (ORs ~ 0.60) versus the instrumental variable approach (OR = 1.04). The ecological analysis also resulted in a non-significant negative association (0.03% lower probability).
Discussion and conclusion
Both magnitude and direction of the estimated treatment effects for both interventions depend strongly on the statistical approach and thus on the source of (unmeasured) confounding. These issues should be understood concerning the specific characteristics of data, before applying an approach and interpreting the results. Instrumental variable analysis might be considered when unobserved confounding and practice variation is expected in observational multicenter studies.
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Román LS, Menon BK, Blasco J, Hernández-Pérez M, Dávalos A, Majoie CBLM, Campbell BCV, Guillemin F, Lingsma H, Anxionnat R, Epstein J, Saver JL, Marquering H, Wong JH, Lopes D, Reimann G, Desal H, Dippel DWJ, Coutts S, du Mesnil de Rochemont R, Yavagal D, Ferre JC, Roos YBWEM, Liebeskind DS, Lenthall R, Molina C, Al Ajlan FS, Reddy V, Dowlatshahi D, Sourour NA, Oppenheim C, Mitha AP, Davis SM, Weimar C, van Oostenbrugge RJ, Cobo E, Kleinig TJ, Donnan GA, van der Lugt A, Demchuk AM, Berkhemer OA, Boers AMM, Ford GA, Muir KW, Brown BS, Jovin T, van Zwam WH, Mitchell PJ, Hill MD, White P, Bracard S, Goyal M, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S, Wakhloo A, Moonis M, Henniger N, Goddeau R, van den Berg R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Tunguturi A, Onteddu S, Carandang R, Howk M, Koudstaal PJ, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Meler P, Huerga E, Gelabert S, Coscojuela P, van Zwam WH, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Rovira A, Molina CA, Millán M, Muñoz L, Roos YB, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, García Bermejo P, Remollo S, Castaño C, García-Sort R, van der Lugt A, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Dávalos A, Chamorro A, Urra X, Obach V, van Oostenbrugge RJ, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Ariño H, Aceituno A, Rudilosso S, Renu A, Majoie CB, Macho JM, San Roman L, Blasco J, López A, Macías N, Cardona P, Quesada H, Rubio F, Cano L, Lara B, Dippel DW, de Miquel MA, Aja L, Serena J, Cobo E, Albers GW, Lees KR, Arenillas J, Roberts R, Minhas P, Al-Ajlan F, Brown MM, Salluzzi M, Zimmel L, Patel S, Eesa M, Martí-Fàbregas J, Jankowitz B, Serena J, Salvat-Plana M, López-Cancio E, Bracard S, Liebig T, Ducrocq X, Anxionnat R, Baillot PA, Barbier C, Derelle AL, Lacour JC, Richard S, Samson Y, Sourour N, Baronnet-Chauvet F, Stijnen T, Clarencon F, Crozier S, Deltour S, Di Maria F, Le Bouc R, Leger A, Mutlu G, Rosso C, Szatmary Z, Yger M, Andersson T, Zavanone C, Bakchine S, Pierot L, Caucheteux N, Estrade L, Kadziolka K, Leautaud A, Renkes C, Serre I, Desal H, Mattle H, Guillon B, Boutoleau-Bretonniere C, Daumas-Duport B, De Gaalon S, Derkinderen P, Evain S, Herisson F, Laplaud DA, Lebouvier T, Lintia-Gaultier A, Wahlgren N, Pouclet-Courtemanche H, Rouaud T, Rouaud Jaffrenou V, Schunck A, Sevin-Allouet M, Toulgoat F, Wiertlewski S, Gauvrit JY, Ronziere T, Cahagne V, van der Heijden E, Ferre JC, Pinel JF, Raoult H, Mas JL, Meder JF, Al Najjar-Carpentier AA, Birchenall J, Bodiguel E, Calvet D, Domigo V, Ghannouti N, Godon-Hardy S, Guiraud V, Lamy C, Majhadi L, Morin L, Naggara O, Trystram D, Turc G, Berge J, Sibon I, Fleitour N, Menegon P, Barreau X, Rouanet F, Debruxelles S, Kazadi A, Renou P, Fleury O, Pasco-Papon A, Dubas F, Caroff J, Hooijenga I, Godard Ducceschi S, Hamon MA, Lecluse A, Marc G, Giroud M, Ricolfi F, Bejot Y, Chavent A, Gentil A, Kazemi A, Puppels C, Osseby GV, Voguet C, Mahagne MH, Sedat J, Chau Y, Suissa L, Lachaud S, Houdart E, Stapf C, Buffon Porcher F, Pellikaan W, Chabriat H, Guedin P, Herve D, Jouvent E, Mawet J, Saint-Maurice JP, Schneble HM, Turjman F, Nighoghossian N, Berhoune NN, Geerling A, Bouhour F, Cho TH, Derex L, Felix S, Gervais-Bernard H, 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Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
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Campbell BCV, van Zwam WH, Goyal M, Menon BK, Dippel DWJ, Demchuk AM, Bracard S, White P, Dávalos A, Majoie CBLM, van der Lugt A, Ford GA, de la Ossa NP, Kelly M, Bourcier R, Donnan GA, Roos YBWEM, Bang OY, Nogueira RG, Devlin TG, van den Berg LA, Clarençon F, Burns P, Carpenter J, Berkhemer OA, Yavagal DR, Pereira VM, Ducrocq X, Dixit A, Quesada H, Epstein J, Davis SM, Jansen O, Rubiera M, Urra X, Micard E, Lingsma HF, Naggara O, Brown S, Guillemin F, Muir KW, van Oostenbrugge RJ, Saver JL, Jovin TG, Hill MD, Mitchell PJ, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle J, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach Z, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Wakhloo A, Moonis M, Henninger N, Goddeau R, Massari F, Minaeian A, Lozano JD, Ramzan M, Stout C, Patel A, Majoie CB, Tunguturi A, Onteddu S, Carandang R, Howk M, Ribó M, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Dippel DW, Meler P, Huerga E, Gelabert S, Coscojuela P, Tomasello A, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Brown MM, Rovira A, Molina CA, Millán M, Muñoz L, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, Liebig T, García Bermejo P, Remollo S, Castaño C, García-Sort R, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Stijnen T, Dávalos A, Chamorro A, Urra X, Obach V, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Andersson T, Ariño 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N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
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Mulder MJ, Ergezen S, Lingsma HF, Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lycklama à Nijeholt G, Emmer BJ, van der Worp HB, Nederkoorn PJ, Roos YB, van Oostenbrugge RJ, van Zwam WH, Majoie CB, van der Lugt A, Dippel DW, Schonewille WJ, Vos JA, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Boiten J, Brouwer PA, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van den Berg JS, van Rooij WJJ, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, van Walderveen MA, Bot JC, Marquering HA, Beenen LF, Sprengers ME, Jenniskens SF, van den Berg R, Yoo AJ, Koudstaal PJ, Boiten J, van Dijk EJ, Wermer MJ, Flach HZ, Steyerberg EW. Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). Stroke 2017; 48:1869-1876. [DOI: 10.1161/strokeaha.116.016225] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/23/2017] [Accepted: 03/01/2017] [Indexed: 12/21/2022]
Abstract
Background and Purpose—
High blood pressure (BP) is associated with poor outcome and the occurrence of symptomatic intracranial hemorrhage in acute ischemic stroke. Whether BP influences the benefit or safety of intra-arterial treatment (IAT) is not known. We aimed to assess the relation of BP with functional outcome, occurrence of symptomatic intracranial hemorrhage and effect of IAT.
Methods—
This is a post hoc analysis of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). BP was measured at baseline, before IAT or stroke unit admission. We estimated the association of baseline BP with the score on the modified Rankin Scale at 90 days and safety parameters with ordinal and logistic regression analysis. Effect of BP on the effect of IAT was tested with multiplicative interaction terms.
Results—
Systolic BP (SBP) had the best correlation with functional outcome. This correlation was U-shaped; both low and high baseline SBP were associated with poor functional outcome. Higher SBP was associated with symptomatic intracranial hemorrhage (adjusted odds ratio, 1.25 for every 10 mm Hg higher SBP [95% confidence interval, 1.09–1.44]). Between SBP and IAT, there was no interaction for functional outcome, symptomatic intracranial hemorrhage, or other safety parameters; the absolute benefit of IAT was evident for the whole SBP range. The same was found for diastolic BP.
Conclusions—
BP does not affect the benefit or safety of IAT in patients with acute ischemic stroke caused by proximal intracranial vessel occlusion. Our data provide no arguments to withhold or delay IAT based on BP.
Clinical Trial Registration—
URL:
http://www.isrctn.com
. Unique identifier: ISRCTN10888758.
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Affiliation(s)
- Maxim J.H.L. Mulder
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Saliha Ergezen
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Hester F. Lingsma
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Olvert A. Berkhemer
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Puck S.S. Fransen
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Debbie Beumer
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Lucie A. van den Berg
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Geert Lycklama à Nijeholt
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Bart J. Emmer
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - H. Bart van der Worp
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Paul J. Nederkoorn
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Yvo B.W.E.M. Roos
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Robert J. van Oostenbrugge
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Wim H. van Zwam
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Charles B.L.M. Majoie
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Aad van der Lugt
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | - Diederik W.J. Dippel
- From the Department of Neurology, (M.J.H.L.M., S.E., O.A.B., P.S.S.F., D.W.J.D.), Department of Radiology (M.J.H.L.M., B.J.E., A.v.d.L.), and Department of Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology (L.A.v.d.B., P.J.N., Y.B.W.E.M.R.) and Department of Radiology (O.A.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands; Department of Neurology (D.B., R.J.v.O.) and Department of Radiology (O.A.B., W.H.v.Z.),
| | | | - Jan Albert Vos
- Radiology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Julie Staals
- Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), the Netherlands
| | | | | | - Jelis Boiten
- Neurology, MC Haaglanden, the Hague, the Netherlands
| | | | | | | | - L. Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, the Netherlands
| | - Rob H. Lo
- Radiology, University Medical Center Utrecht, the Netherlands
| | - Ewoud J. van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost de Vries
- Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul L.M. de Kort
- Department of Neurology, Sint Elisabeth Hospital, Tilburg, the Netherlands
| | | | | | | | - Leo A.M. Aerden
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Marieke C. Visser
- Department of Neurology, VU Medical Center, Amsterdam, the Netherlands
| | | | - Patrick C. Vroomen
- Department of Neurology, University Medical Center Groningen, the Netherlands
| | - Omid Eshghi
- Radiology, University Medical Center Groningen, the Netherlands
| | | | | | - Koos Keizer
- Department of Neurology, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | - Dick G. Gerrits
- Radiology, Medical Spectrum Twente, Enschede, the Netherlands)
| | | | - Giorgos B. Karas
- Radiology, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands
| | | | | | - Henk A. Marquering
- Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | - Ludo F. Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - René van den Berg
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Peter J. Koudstaal
- Department of Neurology, Erasmus MC University Medical Center, the Netherlands
| | - Jelis Boiten
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherland
| | - Ewoud J. van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Ewout W. Steyerberg
- Public Health, Erasmus MC University Medical Center, the Netherlands; Medical Statistics and Bioinformatics, Leiden University Medical Center, the Netherlands
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7
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Berkhemer OA, Jansen IG, Beumer D, Fransen PS, van den Berg LA, Yoo AJ, Lingsma HF, Sprengers ME, Jenniskens SF, Lycklama à Nijeholt GJ, van Walderveen MA, van den Berg R, Bot JC, Beenen LF, Boers AM, Slump CH, Roos YB, van Oostenbrugge RJ, Dippel DW, van der Lugt A, van Zwam WH, Marquering HA, Majoie CB, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, Staals J, Hofmeijer J, van Oostayen JA, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van den Berg JS, van Hassel BA, Aerden LA, Dallinga RJ, Visser MC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Koudstaal PJ, Flach HZ, Steyerberg EW, Brown MM, Liebig T, Stijnen T. Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke. Stroke 2016; 47:768-76. [PMID: 26903582 DOI: 10.1161/strokeaha.115.011788] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 12/10/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN).
Methods—
MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status.
Results—
We found a significant modification of treatment effect by collaterals (
P
=0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7–6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0–2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7–2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1–8.7] for patients with absent collaterals (grade 0).
Conclusions—
In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals.
Clinical Trial Registration—
URL:
http://www.trialregister.nl
and
http://www.controlled-trials.com
. Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.
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Affiliation(s)
- Olvert A. Berkhemer
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Ivo G.H. Jansen
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Debbie Beumer
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Puck S.S. Fransen
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Lucie A. van den Berg
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Albert J. Yoo
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Hester F. Lingsma
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Marieke E.S. Sprengers
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Sjoerd F.M. Jenniskens
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Geert J. Lycklama à Nijeholt
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Marianne A.A. van Walderveen
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - René van den Berg
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Joseph C.J. Bot
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Ludo F.M. Beenen
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Anna M.M. Boers
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Cornelis H. Slump
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Yvo B.W.E.M. Roos
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Robert J. van Oostenbrugge
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Diederik W.J. Dippel
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Aad van der Lugt
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Wim H. van Zwam
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Henk A. Marquering
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
| | - Charles B.L.M. Majoie
- From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.),
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8
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Fransen PSS, Berkhemer OA, Lingsma HF, Beumer D, van den Berg LA, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama À Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PLM, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Visser MC, Bot JCJ, Vroomen PC, Eshghi O, Schreuder THCML, Heijboer RJJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers MES, Jenniskens SFM, Beenen LFM, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YBWEM, van Oostenbrugge RJ, Majoie CBLM, van der Lugt A, Dippel DWJ. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol 2015; 73:190-6. [PMID: 26716735 DOI: 10.1001/jamaneurol.2015.3886] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Intra-arterial treatment (IAT) for acute ischemic stroke caused by intracranial arterial occlusion leads to improved functional outcome in patients treated within 6 hours after onset. The influence of treatment delay on treatment effect is not yet known. OBJECTIVE To evaluate the influence of time from stroke onset to the start of treatment and from stroke onset to reperfusion on the effect of IAT. DESIGN, SETTING, AND PARTICIPANTS The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a multicenter, randomized clinical open-label trial of IAT vs no IAT in 500 patients. The time to the start of treatment was defined as the time from onset of symptoms to groin puncture (TOG). The time from onset of treatment to reperfusion (TOR) was defined as the time to reopening the vessel occlusion or the end of the procedure in cases for which reperfusion was not achieved. Data were collected from December 3, 2010, to June 3, 2014, and analyzed (intention to treat) from July 1, 2014, to September 19, 2015. MAIN OUTCOMES AND MEASURES Main outcome was the modified Rankin Scale (mRS) score for functional outcome (range, 0 [no symptoms] to 6 [death]). Multiple ordinal logistic regression analysis estimated the effect of treatment and tested for the interaction of time to randomization, TOG, and TOR with treatment. The effect of treatment as a risk difference on reaching independence (mRS score, 0-2) was computed as a function of TOG and TOR. Calculations were adjusted for age, National Institutes of Health Stroke Scale score, previous stroke, atrial fibrillation, diabetes mellitus, and intracranial arterial terminus occlusion. RESULTS Among 500 patients (58% male; median age, 67 years), the median TOG was 260 (interquartile range [IQR], 210-311) minutes; median TOR, 340 (IQR, 274-395) minutes. An interaction between TOR and treatment (P = .04) existed, but not between TOG and treatment (P = .26). The adjusted risk difference (95% CI) was 25.9% (8.3%-44.4%) when reperfusion was reached at 3 hours, 18.8% (6.6%-32.6%) at 4 hours, and 6.7% (0.4%-14.5%) at 6 hours. CONCLUSION AND RELEVANCE For every hour of reperfusion delay, the initially large benefit of IAT decreases; the absolute risk difference for a good outcome is reduced by 6% per hour of delay. Patients with acute ischemic stroke require immediate diagnostic workup and IAT in case of intracranial arterial vessel occlusion. TRIAL REGISTRATION trialregister.nl Identifier: NTR1804.
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Affiliation(s)
- Puck S S Fransen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands2Department of Radiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olvert A Berkhemer
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands3Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Debbie Beumer
- Department of Neurology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | | | | | | | - Jan Albert Vos
- Department of Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Julie Staals
- Department of Neurology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | | | | | | | - Jelis Boiten
- Department of Neurology, Medisch Centrum Haaglanden, the Hague, the Netherlands
| | - Patrick A Brouwer
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Lukas C van Dijk
- Department of Radiology, Haga Hospital, the Hague, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rob H Lo
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ewoud J van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost de Vries
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul L M de Kort
- Department of Neurology, St Elisabeth Hospital, Tilburg, the Netherlands
| | | | | | - Leo A M Aerden
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - René J Dallinga
- Department of Radiology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Marieke C Visser
- Department of Neurology, VU Medical Center, Amsterdam, the Netherlands
| | - Joseph C J Bot
- Department of Radiology, VU Medical Center, Amsterdam, the Netherlands
| | - Patrick C Vroomen
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Omid Eshghi
- Department of Radiology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Roel J J Heijboer
- Department of Radiology, Atrium Medical Center, Heerlen, the Netherlands
| | - Koos Keizer
- Department of Neurology, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | - Dick G Gerrits
- Department of Radiology, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Giorgos B Karas
- Department of Radiology, St Lucas Andreas Hospital, Amsterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - H Zwenneke Flach
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Henk A Marquering
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands39Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Sjoerd F M Jenniskens
- Department of Radiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - René van den Berg
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Peter J Koudstaal
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | | | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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9
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Borst J, Berkhemer OA, Roos YB, van Bavel E, van Zwam WH, van Oostenbrugge RJ, van Walderveen MA, Lingsma HF, van der Lugt A, Dippel DW, Yoo AJ, Marquering HA, Majoie CB, Fransen PS, Beumer D, van den Berg LA, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, Brown MM, Liebig T, Stijnen T, Andersson T, Mattle H, Wahlgren N, van der Heijden E, Ghannouti N, Fleitour N, Hooijenga I, Puppels C, Pellikaan W, Geerling A, Lindl-Velema A, van Vemde G, de Ridder A, Greebe P, de Bont-Stikkelbroeck J, de Meris J, Janssen K, Struijk W, Simons T, Messchendorp G, van der Minne F, Bongenaar H, Licher S, Boodt N, Ros A, Venema E, Slokkers I, Ganpat RJ, Mulder M, Saiedie N, Heshmatollah A, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Jansen I, Kappelhof M, Lucas M, Geuskens R, Barros RS, Dobbe R, Csizmadia M. Value of Computed Tomographic Perfusion–Based Patient Selection for Intra-Arterial Acute Ischemic Stroke Treatment. Stroke 2015; 46:3375-82. [DOI: 10.1161/strokeaha.115.010564] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/09/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Jordi Borst
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Olvert A. Berkhemer
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Yvo B.W.E.M. Roos
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Ed van Bavel
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Wim H. van Zwam
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Robert J. van Oostenbrugge
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Marianne A.A. van Walderveen
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Hester F. Lingsma
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Aad van der Lugt
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Diederik W.J. Dippel
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Albert J. Yoo
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Henk A. Marquering
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Charles B.L.M. Majoie
- From the Departments of Radiology (J.B., O.A.B., H.A.M., C.B.L.M.M.), Neurology (Y.B.W.E.M.R.), and Biomedical Engineering and Physics (E.v.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands (M.A.A.v.W.); Departments of
| | - Puck S.S. Fransen
- Departments of Neurology and Radiology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Debbie Beumer
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, The Netherlands and Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
| | | | | | - Jan Albert Vos
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Center Amsterdam, The Netherlands
| | | | - Julie Staals
- Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
| | | | | | | | - Jelis Boiten
- Department of Neurology, MC Haaglanden, the Hague, The Netherlands
| | - Patrick A. Brouwer
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | | | | | - L. Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, The Netherlands
| | - Rob H. Lo
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Ewoud J. van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost de Vries
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul L.M. de Kort
- Department of Neurology, Sint Elisabeth Hospital, Tilburg, The Netherlands
| | | | | | - Leo A.M. Aerden
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - René J. Dallinga
- Department of Radiology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Marieke C. Visser
- Department of Neurology, VU Medical Center, Amsterdam, The Netherlands
| | - Joseph C.J. Bot
- Department of Radiology, VU Medical Center, Amsterdam, The Netherlands
| | - Patrick C. Vroomen
- Department of Neurology, University Medical Center Groningen, The Netherlands
| | - Omid Eshghi
- Department of Radiology, University Medical Center Groningen, The Netherlands
| | | | - Roel J.J. Heijboer
- Department of Radiology, Atrium Medical Center, Heerlen, The Netherlands
| | - Koos Keizer
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | - Dick G. Gerrits
- Department of Radiology, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Giorgos B. Karas
- Department of Radiology, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - H. Zwenneke Flach
- Department of Neurology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | | | - Ludo F.M. Beenen
- Department of Radiology, Academic Medical Center Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology, Academic Medical Center Amsterdam, The Netherlands
| | - Peter J. Koudstaal
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | | | | | - Theo Stijnen
- Leiden University Medical Center, Leiden, the Netherlands
| | - Tommy Andersson
- Neuro Interventionist, Karolinska Univeristy Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | - Annet Geerling
- Radboud University Nijmegen Medical Center, the Netherlands
| | | | | | | | - Paut Greebe
- University Medical Center Utrecht, the Netherlands
| | | | | | | | | | | | | | | | | | - Silvan Licher
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Nikki Boodt
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Adriaan Ros
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Esmee Venema
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Ilse Slokkers
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | | | - Maxim Mulder
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Nawid Saiedie
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | | | | | - Stefan Vinken
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | | | - Jeroen Koets
- Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Merel Boers
- Academic Medical Center Amsterdam, the Netherlands
| | | | - Ivo Jansen
- Academic Medical Center Amsterdam, the Netherlands
| | | | - Marit Lucas
- Academic Medical Center Amsterdam, the Netherlands
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10
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Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PLM, van Rooij WJJ, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Visser MC, Bot JCJ, Vroomen PC, Eshghi O, Schreuder THCML, Heijboer RJJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers MES, Jenniskens SFM, Beenen LFM, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YBWEM, van der Lugt A, van Oostenbrugge RJ, Majoie CBLM, Dippel DWJ. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372:11-20. [PMID: 25517348 DOI: 10.1056/nejmoa1411587] [Citation(s) in RCA: 4479] [Impact Index Per Article: 497.7] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, intraarterial treatment is highly effective for emergency revascularization. However, proof of a beneficial effect on functional outcome is lacking. METHODS We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). RESULTS We enrolled 500 patients at 16 medical centers in The Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. CONCLUSIONS In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.).
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11
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van der Lugt JCT, de Graaf PW, Dallinga RJ, Stassen LPS. [Abscess formation due to lost stones during laparoscopic cholecystectomy]. Ned Tijdschr Geneeskd 2005; 149:2683-6. [PMID: 16358619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Two women aged 79 and 69 years presented with abdominal pain at 15 and 38 months respectively after a laparoscopic cholecystectomy. In both cases perforation of the gallbladder had occurred with spillage of bile and gallstones. A CT-scan carried out at presentation showed signs of an abdominal abscess. The origin of the abscess was initially unknown. The first patient was operated on immediately. In the second patient a drain was placed in the abscess under ultrasound guidance. During operation gallstones were seen in the abscess cavity in both patients. Both patients recovered well. Although perforation of the gallbladder with spillage of gallstones during laparoscopic cholecystectomy often occurs, the incidence of major postoperative complications is low. However, in some cases reoperation is necessary. Removal of all spilled stones is therefore indicated to prevent complications. If abdominal symptoms persist after laparoscopic cholecystectomy, an abscess due to spilled gallstones should be considered. Ultra-sound or CT are the most sensitive means of for tracing spilled gallstones or abscesses.
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Abstract
In the past, osteochondritis dissecans of the knee was associated with increased tibial exotorsion, established with a clinical measuring method. Now the gold standard for determining tibial torsion is computed tomography. The aim of the current study was to establish whether the abovementioned association could be confirmed in the current patients, measured with computed tomography. Confounding aberrations of femoral torsion were ruled out. Twenty-three patients with osteochondritis dissecans in 27 knees were treated between 1991 and 1999. Symptoms and treatment results were comparable with those reported in the literature. Femoral and tibial torsion were measured with a computed tomography scan. The average femoral antetorsion was comparable with that in the literature. The average tibial exotorsion was significantly higher than the control value. Exotorsion was increased more in patients with bilateral osteochondritis, and extremely high in patients with persisting complaints. Increased tibial exotorsion could play a role in development of osteochondritis dissecans of the knee. Extreme exotorsion might be prognostic for persistent complaints.
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Affiliation(s)
- J A M Bramer
- Orthopaedic Research Center Amsterdam, Amsterdam, the Netherlands.
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van der Hul RL, van Overhagen H, Dallinga RJ, de Graaf PW. Splenic salvage by superselective embolisation after blunt abdominal trauma. Eur J Surg 2001; 167:73-5. [PMID: 11213827 DOI: 10.1080/110241501750069873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- R L van der Hul
- Department of Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
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Abstract
The effect of a single blood transfusion on the formation and outgrowth of experimental lung metastases was assessed in two tumor models in rats. The transfusions were given either 1 week before (day -7) or 1 week after (day +7) tumor cell inoculation. The first approach was performed to investigate the effect of transfusions on the formation of lung colonies, the second approach to study the effect on the outgrowth of established metastases. The first tumor model used was a transplantable, nonimmunogenic sarcoma (LS175) in BN rats. Animals were injected i.v. with 10(5) tumor cells and the number of metastases developing in the lungs was counted after 18 days. Experimental animals received 1 ml of allogeneic WAG blood, controls were given 1 ml of syngeneic BN blood. A single allogeneic transfusion given on day -7 had no effect on the formation of LS175 lung colonies but, when given day +7, stimulated the outgrowth of established metastases. The second tumor model was a highly immunogenic transplantable basal cell carcinoma (BC1618) in inbred WAG rats. Rats were injected i.v. with 10(6) tumor cells and the numbers of lung colonies were counted after 21 days. Experimental animals were transfused with 1 ml of BN blood, controls received 1 ml of WAG blood. An allogeneic transfusion on day -7 led to a significant inhibition of lung metastases, whereas a transfusion on day +7 had no effect. The results clearly indicate that allogeneic blood transfusions can modulate tumor growth and metastasis. Although immunological factors seem to play a crucial role in this transfusion phenomenon, there was no clear-cut correlation between the observed effects (accelerated tumor growth vs inhibition of metastasis) and the type of immunomodulation evoked.
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