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Samuels N, van de Graaf RA, Roos YBWM, Dippel D, van der Lugt A. Advancements in diagnostic and interventional radiology for stroke treatment: the path from trial to bedside through the pre-MR CLEAN, MR CLEAN, and MR CLEAN II eras. Insights Imaging 2024; 15:30. [PMID: 38289430 PMCID: PMC10828318 DOI: 10.1186/s13244-023-01597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/31/2023] [Accepted: 11/20/2023] [Indexed: 02/02/2024] Open
Abstract
The stroke field is inevitably connected with imaging in which radiologists fulfill a central role. Our landmark MR CLEAN trial led to the implementation of baseline computed tomography angiography or magnetic resonance angiography in the acute stroke workup and subsequent endovascular treatment (EVT) for ischemic stroke patients with a large vessel occlusion in the anterior circulation, resulting in numerous patients worldwide currently being treated often successfully. A reversal of the pathophysiologic process behind an acute cerebrovascular event was made possible. Subsequently, in the MR CLEAN II trials, the clinical impact of both diagnostic and interventional radiologists remained a cornerstone of our research, which means value-based radiology. Within these MR CLEAN II trials, we proved that aspirin and heparin during EVT should be avoided due to increased symptomatic intracranial hemorrhage risk (MR CLEAN-MED). We concluded there is additional benefit of EVT in the 6-to-24-h window after stroke in the presence of good collaterals on baseline CTA (MR CLEAN-LATE). The impactful success of our stroke trials that changed many guidelines was mainly attributable to (1) the societal burden of the disease, with two thirds of patients dying or being independent at 3 months; (2) the fact that stroke is a common disease, (3) the relatively simple and pragmatic approach of the trials resembling real-world setting; (4) the acceleration of implementation in clinical practice facilitated by a structured approach to guideline development and conditional funding; and foremost (5) the excellent collaboration on a professional level between-disciplines, i.e., diagnostic radiologists, interventionalists, and neurologists.Critical relevance statement The MR CLEAN and MR CLEAN II trials have had tremendous impact on clinical practice, directly by more patients being treated with an effective intervention and indirectly through adoption of evidence-based guidelines. It is in this setting of stroke treatment that diagnostic and interventional radiologists have played a crucial role and created clinical impact.
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Affiliation(s)
- Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Yvo B W M Roos
- Department of Neurology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Samuels N, van de Graaf RA, Mulder MJHL, Brown S, Roozenbeek B, van Doormaal PJ, Goyal M, Campbell BCV, Muir KW, Agrinier N, Bracard S, White PM, Román LS, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Bonafe A, Devlin TG, van Es ACGM, Lingsma HF, Dippel DWJ, van der Lugt A. Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis. Lancet Neurol 2023; 22:312-319. [PMID: 36931806 DOI: 10.1016/s1474-4422(23)00076-5] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy. METHODS We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis. FINDINGS We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81-0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88-1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96). INTERPRETATION In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility. FUNDING Medtronic.
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Affiliation(s)
- Noor Samuels
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Scott Brown
- BRIGHT Research Partners, Mooresville, NC, USA
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nelly Agrinier
- Centre Hospitalier Régional Universitaire Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University of Lorraine and University Hospital of Nancy, France
| | - Phil M White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Luis San Román
- Neuroradiology Service, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, NJ, USA
| | - Michael D Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew M Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alain Bonafe
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier-Guy de Chauliac, Montpellier, France
| | - Thomas G Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
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van der Steen W, van der Sluijs PM, van de Graaf RA, Su R, Wolff L, van Voorst H, den Hertog HM, van Doormaal PJ, van Es ACGM, Staals J, van Zwam W, Lingsma HF, van den Berg R, Majoie CBLM, van der Lugt A, Dippel DWJ, Roozenbeek B. Safety and efficacy of periprocedural antithrombotics in patients with successful reperfusion after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2022; 31:106726. [PMID: 36029687 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106726] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/08/2022] [Revised: 08/08/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We aimed to evaluate whether the overall harmful effect of periprocedural treatment with aspirin or heparin during endovascular stroke treatment is different in patients with a successful reperfusion after the procedure. MATERIALS AND METHODS We performed a post-hoc analysis of the MR CLEAN-MED trial, including adult patients with a large vessel occlusion in the anterior circulation eligible for endovascular treatment (EVT). In this trial, patients were randomized for periprocedural intravenous treatment with aspirin or no aspirin (1:1 ratio), and for moderate-dose unfractionated heparin, low-dose unfractionated heparin or no unfractionated heparin (1:1:1 ratio). We tested for interaction between the post-EVT extended thrombolysis in cerebral infarction (eTICI) score and treatment with periprocedural medication with multivariable regression analyses. The primary outcome was the modified Rankin Scale score at 90 days. Secondary outcomes were final infarct volume, intracranial hemorrhage, and symptomatic intracranial hemorrhage. RESULTS Of 534 included patients, 93 (17%) had a post-EVT eTICI score of 0-2a, 115 (22%) a score of 2b, 73 (14%) a score of 2c, and 253 (47%) a score of 3. For both aspirin and heparin, we found no interaction between post-EVT eTICI score and treatment on the modified Rankin Scale score (p=0.76 and p=0.47, respectively). We found an interaction between post-EVT eTICI score and treatment with heparin on the final infarct volume (p=0.01). Of note, this interaction showed a biologically implausible distribution over the subgroups. CONCLUSIONS The overall harmful effect of periprocedural aspirin and unfractionated heparin is not different in patients with a successful reperfusion after EVT.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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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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5
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Samuels N, van de Graaf RA, van den Berg CAL, Uniken Venema SM, Bala K, van Doormaal PJ, van der Steen W, Witvoet E, Boiten J, den Hertog H, Schonewille WJ, Hofmeijer J, Schreuder F, Schreuder TAHCML, van der Worp HB, Roos YBWEM, Majoie CBLM, Burke JF, van Es ACGM, van der Lugt A, Roozenbeek B, Lingsma HF, Dippel DWJ. Blood Pressure in the First 6 Hours Following Endovascular Treatment for Ischemic Stroke Is Associated With Outcome. Stroke 2021; 52:3514-3522. [PMID: 34538090 PMCID: PMC8547588 DOI: 10.1161/strokeaha.120.033657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Optimal blood pressure (BP) management in the acute phase of ischemic stroke remains an unresolved issue. It is uncertain whether guidelines for BP management during and after intravenous alteplase can be extrapolated to endovascular treatment (EVT) for stroke due to large artery occlusion in the anterior circulation. We evaluated the associations between systolic BP (SBP) in the first 6 hours following EVT and functional outcome as well as symptomatic intracranial hemorrhage. Methods: Patients of 8 MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry centers, with available data on SBP in the 6 hours following EVT, were analyzed. We evaluated maximum, minimum, and mean SBP. Study outcomes were functional outcome (modified Rankin Scale) at 90 days and symptomatic intracranial hemorrhage. We used multivariable ordinal and binary regression analysis to adjust for important prognostic factors and studied possible effect modification by successful reperfusion. Results: Post-EVT SBP data were available for 1161/1796 patients. Higher maximum SBP (per 10 mm Hg increments) was associated with worse functional outcome (adjusted common odds ratio, 0.93 [95% CI, 0.88–0.98]) and a higher rate of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.17 [95% CI, 1.02–1.36]). The association between minimum SBP and functional outcome was nonlinear with an inflection point at 124 mm Hg. Minimum SBP lower and higher than the inflection point were associated with worse functional outcomes (adjusted common odds ratio, 0.85 per 10 mm Hg decrements [95% CI, 0.76–0.95] and adjusted common odds ratio, 0.81 per 10 mm Hg increments [95% CI, 0.71–0.92]). No association between mean SBP and functional outcome was observed. Successful reperfusion did not modify the relation of SBP with any of the outcomes. Conclusions: Maximum SBP in the first 6 hours following EVT is positively associated with worse functional outcome and an increased risk of symptomatic intracranial hemorrhage. Both lower and higher minimum SBP are associated with worse outcomes. A randomized trial to evaluate whether modifying post-intervention SBP results in better outcomes after EVT for ischemic stroke seems justified.
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Affiliation(s)
- Noor Samuels
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Carlijn A L van den Berg
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Kujtesa Bala
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wouter van der Steen
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Elbert Witvoet
- Department of Neurology, Haga Hospital, Den Haag, the Netherlands (E.W.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center, Den Haag, the Netherlands (J.B.)
| | - Heleen den Hertog
- Department of Neurology, Isala Hospital, Zwolle, the Netherlands (H.d.H.)
| | - Wouter J Schonewille
- Department of Neurology, Sint Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | | | - Floris Schreuder
- Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands (F.S.)
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Centers, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (C.B.L.M.M.), Amsterdam University Medical Centers, the Netherlands
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor (J.F.B.)
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., P.J.v.D., W.v.d.S., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health (N.S., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (N.S., R.A.v.d.G., K.B., W.v.d.S., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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6
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van de Graaf RA, Samuels N, Chalos V, Lycklama A Nijeholt GJ, van Beusekom H, Yoo AJ, van Zwam WH, Majoie CBLM, Roos YBWEM, van Doormaal PJ, Ben Hassen W, van der Lugt A, Dippel DWJ, Lingsma HF, van Es ACGM, Roozenbeek B. Predictors of poor outcome despite successful endovascular treatment for ischemic stroke: results from the MR CLEAN Registry. J Neurointerv Surg 2021; 14:660-665. [PMID: 34266905 DOI: 10.1136/neurintsurg-2021-017726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/02/2021] [Accepted: 07/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Approximately one-third of patients with ischemic stroke treated with endovascular treatment do not recover to functional independence despite rapid and successful recanalization. We aimed to quantify the importance of predictors of poor functional outcome despite successful reperfusion. METHODS We analyzed patients from the MR CLEAN Registry between March 2014 and November 2017 with successful reperfusion (extended Thrombolysis In Cerebral Infarction ≥2B). First, predictors were selected based on expert opinion and were clustered according to acquisition over time (ie, baseline patient factors, imaging factors, treatment factors, and postprocedural factors). Second, several models were constructed to predict 90-day functional outcome (modified Rankin Scale (mRS)). The relative importance of individual predictors in the most extensive model was expressed by the proportion of unique added χ2 to the model of that individual predictor. RESULTS Of 3180 patients, 1913 (60%) had successful reperfusion. Of these 1913 patients, 1046 (55%) were functionally dependent at 90 days (mRS >2). The most important predictors for mRS were baseline patient factors (ie, pre-stroke mRS, added χ2 0.16; National Institutes of Health Stroke Scale score at baseline, added χ2 0.12; age, added χ2 0.10), and postprocedural factors (ie, symptomatic intracranial hemorrhage (sICH), added χ2 0.12; pneumonia, added χ2 0.09). The probability of functional independence for a typical stroke patient with sICH was 54% (95% CI 36% to 72%) lower compared with no sICH, and 21% (95% CI 4% to 38%) for pneumonia compared with no pneumonia. CONCLUSION Baseline patient factors and postprocedural adverse events are important predictors of poor functional outcome in successfully reperfused patients with ischemic stroke. This implies that prevention of postprocedural adverse events has the greatest potential to further improve outcomes in these patients.
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Affiliation(s)
- Rob A van de Graaf
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands .,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Noor Samuels
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Vicky Chalos
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Heleen van Beusekom
- Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Wim H van Zwam
- Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Pieter Jan van Doormaal
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wagih Ben Hassen
- Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | - Hester F Lingsma
- Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan C G M van Es
- Radiology and Nuclear Medicine, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Bob Roozenbeek
- Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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7
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Samuels N, van de Graaf RA, van den Berg CAL, Nieboer D, Eralp I, Treurniet KM, Emmer BJ, Immink RV, Majoie CBLM, van Zwam WH, Bokkers RPH, Uyttenboogaart M, van Hasselt BAAM, Mühling J, Burke JF, Roozenbeek B, van der Lugt A, Dippel DWJ, Lingsma HF, van Es ACGM. Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia. Neurology 2020; 96:e171-e181. [PMID: 33028664 PMCID: PMC7905780 DOI: 10.1212/wnl.0000000000011006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 04/10/2020] [Accepted: 08/24/2020] [Indexed: 12/27/2022] Open
Abstract
Objective To evaluate the role of blood pressure (BP) as mediator of the effect of conscious sedation (CS) compared to local anesthesia (LA) on functional outcome after endovascular treatment (EVT). Methods Patients treated in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry centers with CS or LA as preferred anesthetic approach during EVT for ischemic stroke were analyzed. First, we evaluated the effect of CS on area under the threshold (AUT), relative difference between baseline and lowest procedural mean arterial pressure (∆LMAP), and procedural BP trend, compared to LA. Second, we assessed the association between BP and functional outcome (modified Rankin Scale [mRS]) with multivariable regression. Lastly, we evaluated whether BP explained the effect of CS on mRS. Results In 440 patients with available BP data, patients treated under CS (n = 262) had larger AUTs (median 228 vs 23 mm Hg*min), larger ∆LMAP (median 16% vs 6%), and a more negative BP trend (−0.22 vs −0.08 mm Hg/min) compared to LA (n = 178). Larger ∆LMAP and AUTs were associated with worse mRS (adjusted common odds ratio [acOR] per 10% drop 0.87, 95% confidence interval [CI] 0.78–0.97, and acOR per 300 mm Hg*min 0.89, 95% CI 0.82–0.97). Patients treated under CS had worse mRS compared to LA (acOR 0.59, 95% CI 0.40–0.87) and this association remained when adjusting for ∆LMAP and AUT (acOR 0.62, 95% CI 0.42–0.92). Conclusions Large BP drops are associated with worse functional outcome. However, BP drops do not explain the worse outcomes in the CS group.
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Affiliation(s)
- Noor Samuels
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
| | - Rob A van de Graaf
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Carlijn A L van den Berg
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Daan Nieboer
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ismail Eralp
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Kilian M Treurniet
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bart J Emmer
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Rogier V Immink
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Charles B L M Majoie
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Wim H van Zwam
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Reinoud P H Bokkers
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Maarten Uyttenboogaart
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Boudewijn A A M van Hasselt
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Jörg Mühling
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Aad van der Lugt
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Hester F Lingsma
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Radiology & Nuclear Medicine (N.S., R.A.v.d.G., C.A.L.v.d.B., B.R., A.v.d.L., A.C.G.M.v.E.), Public Health (D.N., H.F.L.), Anesthesiology (I.E.), and Neurology (N.S., R.A.v.d.G., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology & Nuclear Medicine (K.M.T., B.J.E., C.B.L.M.M.) and Anesthesiology (R.V.I.), Amsterdam University Medical Center, University of Amsterdam; Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center; Departments of Radiology and Nuclear Medicine (R.P.H.B., M.U.) and Neurology (M.U.), University Medical Center Groningen; Department of Radiology and Nuclear Medicine (B.A.A.M.v.H.), Isala, Zwolle; Department of Anesthesiology, Pain & Palliative Medicine (J.M.), Radboud UMC, University Medical Center, Nijmegen, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
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8
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van de Graaf RA, Zinkstok SM, Chalos V, Goldhoorn RJB, Majoie CB, van Oostenbrugge RJ, van der Lugt A, Dippel DW, Roos YB, Lingsma HF, van Es AC, Roozenbeek B. Prior antiplatelet therapy in patients undergoing endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry. Int J Stroke 2020; 16:476-485. [PMID: 32791940 PMCID: PMC8193619 DOI: 10.1177/1747493020946975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Antiplatelet therapy may increase the risk of symptomatic intracranial hemorrhage after endovascular treatment for ischemic stroke but may also have a beneficial effect on functional outcome. The aim of this study is to compare safety and efficacy outcomes after endovascular treatment in patients with and without prior antiplatelet therapy. Methods We analyzed patients registered in the MR CLEAN Registry between March 2014 and November 2017, for whom data on antiplatelet therapy were available. We used propensity score nearest-neighbor matching with replacement to balance the probability of receiving prior antiplatelet therapy between the prior antiplatelet therapy and no prior antiplatelet therapy group and adjusted for baseline prognostic factors to compare these groups. Primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes were 90-day functional outcome (modified Rankin Scale), successful reperfusion (extended thrombolysis in cerebral infarction score ≥2B) and 90-day mortality. Results Thirty percent (n = 937) of the 3154 patients were on prior antiplatelet therapy, who were matched to 477 patients not on prior antiplatelet therapy. Symptomatic intracranial hemorrhage occurred in 74/937 (7.9%) patients on prior antiplatelet therapy and in 27/477 (5.6%) patients without prior antiplatelet therapy adjusted odds ratio 1.47, 95% confidence interval 0.86–2.49. No associations were found between prior antiplatelet therapy and functional outcome (adjusted common odds ratio 0.87, 95% confidence interval 0.65–1.16), successful reperfusion (adjusted odds ratio 1.23, 95% confidence interval 0.77–1.97), or 90-day mortality (adjusted odds ratio 1.15, 95% confidence interval 0.86–1.54). Conclusion We found no evidence of an association of prior antiplatelet therapy with the risk of symptomatic intracranial hemorrhage after endovascular treatment, nor on functional outcome, reperfusion, or mortality. A substantial beneficial or detrimental effect of antiplatelet therapy on clinical outcome cannot be excluded. A randomized clinical trial comparing antiplatelet therapy versus no antiplatelet therapy is needed.
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Affiliation(s)
- Rob A van de Graaf
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sanne M Zinkstok
- Department of Neurology, 3913Tergooi, Hilversum, The Netherlands
| | - Vicky Chalos
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Public Health, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik Wj Dippel
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Location AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan Cgm van Es
- Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, 6993Erasmus MC University Medical Center, Rotterdam, The Netherlands
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9
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Chalos V, A van de Graaf R, Roozenbeek B, C G M van Es A, M den Hertog H, Staals J, van Dijk L, F M Jenniskens S, J van Oostenbrugge R, H van Zwam W, B W E M Roos Y, B L M Majoie C, F Lingsma H, van der Lugt A, W J Dippel D. Multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke. The effect of periprocedural medication: acetylsalicylic acid, unfractionated heparin, both, or neither (MR CLEAN-MED). Rationale and study design. Trials 2020; 21:644. [PMID: 32665035 PMCID: PMC7362523 DOI: 10.1186/s13063-020-04514-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite evidence of a quite large beneficial effect of endovascular treatment (EVT) for ischemic stroke caused by anterior circulation large vessel occlusion, many patients do not recover even after complete recanalization. To some extent, this may be attributable to incomplete microvascular reperfusion, which can possibly be improved by antiplatelet agents and heparin. It is unknown whether periprocedural antithrombotic medication in patients treated with EVT improves functional outcome. The aim of this study is to assess the effect of acetylsalicylic acid (ASA) and unfractionated heparin (UFH), alone, or in combination, given to patients with an ischemic stroke caused by an intracranial large vessel occlusion in the anterior circulation during EVT. METHODS MR CLEAN-MED is a multicenter phase III trial with a prospective, 2 × 3 factorial randomized, open label, blinded end-point (PROBE) design, which aims to enroll 1500 patients. The trial is designed to evaluate the effect of intravenous ASA (300 mg), UFH (low or moderate dose), both or neither as adjunctive therapy to EVT. We enroll adult patients with a clinical diagnosis of stroke (NIHSS ≥ 2) and with a confirmed intracranial large vessel occlusion in the anterior circulation on CTA or MRA, when EVT within 6 h from symptom onset is indicated and possible. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days. Treatment effect on the mRS will be estimated with ordinal logistic regression analysis, with adjustment for main prognostic variables. Secondary outcomes include stroke severity measured with the NIHSS at 24 h and at 5-7 days, follow-up infarct volume, symptomatic intracranial hemorrhage (sICH), and mortality. DISCUSSION Clinical equipoise exists whether antithrombotic medication should be administered during EVT for a large vessel occlusion, as ASA and/or UFH may improve functional outcome, but might also lead to an increased risk of sICH. When one or both of the study treatments show the anticipated effect on outcome, we will be able to improve outcome of patients treated with EVT by 5%. This amounts to more than 50 patients annually in the Netherlands, more than 1800 in Europe, and more than 1300 in the USA. TRIAL REGISTRATION ISRCT, ISRCTN76741621 . Dec 6, 2017.
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Affiliation(s)
- Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lukas van Dijk
- Department of Radiology & Nuclear Medicine, HagaZiekenhuis, Radiology, Den Haag, The Netherlands
| | - Sjoerd F M Jenniskens
- Department of Radiology & Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology & Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, University of Amsterdam, location AMC, Amsterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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10
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Groot AE, Treurniet KM, Jansen IG, Lingsma HF, Hinsenveld W, van de Graaf RA, Roozenbeek B, Willems HC, Schonewille WJ, Marquering HA, van den Berg R, Dippel DW, Majoie CB, Roos YB, Coutinho JM. Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry. Neurology 2020; 95:e131-e139. [DOI: 10.1212/wnl.0000000000009764] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 01/26/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).MethodsWe included consecutive patients (2014–2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome.ResultsOf the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24–0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33–4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04–5.10 vs 2.00, 95% CI 1.56–2.57, pinteraction = 0.026).ConclusionOlder age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.
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11
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Goldhoorn RJB, van de Graaf RA, van Rees JM, Lingsma HF, Dippel DWJ, Hinsenveld WH, Postma A, van den Wijngaard I, van Zwam WH, van Oostenbrugge RJ, Roozenbeek B. Endovascular Treatment for Acute Ischemic Stroke in Patients on Oral Anticoagulants: Results From the MR CLEAN Registry. Stroke 2020; 51:1781-1789. [PMID: 32390550 DOI: 10.1161/strokeaha.119.028675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The use of oral anticoagulants (OAC) is considered a contra-indication for intravenous thrombolytics as acute treatment of ischemic stroke. However, little is known about the risks and benefits of endovascular treatment in patients on prior OAC. We aim to compare outcomes after endovascular treatment between patients with and without prior use of OAC. Methods- Data of patients with acute ischemic stroke caused by an intracranial anterior circulation occlusion, included in the nationwide, prospective, MR CLEAN Registry between March 2014 and November 2017, were analyzed. Outcomes of interest included symptomatic intracranial hemorrhage and functional outcome at 90 days (modified Rankin Scale score). Outcomes between groups were compared with (ordinal) logistic regression analyses, adjusted for prognostic factors. Results- Three thousand one hundred sixty-two patients were included in this study, of whom 502 (16%) used OAC. There was no significant difference in the occurrence of symptomatic intracranial hemorrhage between patients with and without prior OACs (5% versus 6%; adjusted odds ratio, 0.63 [95% CI, 0.38-1.06]). Patients on OACs had worse functional outcomes than patients without OACs (common odds ratio, 0.57 [95% CI, 0.47-0.66]). However, this observed difference in functional outcome disappeared after adjustment for prognostic factors (adjusted common odds ratio, 0.91 [95% CI, 0.74-1.13]). Conclusions- Prior OAC use in patients treated with endovascular treatment for ischemic stroke is not associated with an increased risk of symptomatic intracranial hemorrhage or worse functional outcome compared with no prior OAC use. Therefore, prior OAC use should not be a contra-indication for endovascular treatment.
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Affiliation(s)
- Robert-Jan B Goldhoorn
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Rob A van de Graaf
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam.,Department of Radiology & Nuclear Medicine (R.A.v.d.G., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Jan M van Rees
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Hester F Lingsma
- Department of Public Health (H.F.L.), Erasmus MC, University Medical Center, Rotterdam
| | - Diederik W J Dippel
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Wouter H Hinsenveld
- Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Alida Postma
- Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center.,School for Mental Health and Sciences (Mhens), Maastricht University (A.P.)
| | - Ido van den Wijngaard
- Department of Neurology, Haaglanden Medical Center, The Hague (I.v.d.W.).,Department of Neurology, Leiden University Medical Center (I.v.d.W.)
| | - Wim H van Zwam
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center.,Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Robert J van Oostenbrugge
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Bob Roozenbeek
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
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Samuels N, van de Graaf RA, Dippel DWJ. Letter by Samuels et al Regarding Article, "Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome". Stroke 2019; 50:e320. [PMID: 31623548 DOI: 10.1161/strokeaha.119.026968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Noor Samuels
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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van de Graaf RA, Chalos V, van Es ACGM, Emmer BJ, Lycklama À Nijeholt GJ, van der Worp HB, Schonewille WJ, van der Lugt A, Dippel DWJ, Lingsma HF, Roozenbeek B. Periprocedural Intravenous Heparin During Endovascular Treatment for Ischemic Stroke: Results From the MR CLEAN Registry. Stroke 2019; 50:2147-2155. [PMID: 31860411 PMCID: PMC6661247 DOI: 10.1161/strokeaha.119.025329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety. Methods— Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction ≥2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome. Results— One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%–94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87–1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89–1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65–1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66–1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01–1.13). Conclusions— Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.
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Affiliation(s)
- Rob A van de Graaf
- From the Department of Neurology (R.A.v.d.G., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (R.A.v.d.G., V.C., A.C.G.M.v.E., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Vicky Chalos
- From the Department of Neurology (R.A.v.d.G., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (R.A.v.d.G., V.C., A.C.G.M.v.E., 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
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine (R.A.v.d.G., V.C., A.C.G.M.v.E., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology, Amsterdam University Medical Center, location AMC, the Netherlands (B.L.E.)
| | | | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands (H.B.v.d.W.)
| | - Wouter J Schonewille
- Department of Neurology, Sint Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (R.A.v.d.G., V.C., A.C.G.M.v.E., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- From the Department of Neurology (R.A.v.d.G., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- From the Department of Neurology (R.A.v.d.G., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (R.A.v.d.G., V.C., A.C.G.M.v.E., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Nogueira RG, van de Graaf RA, Mocco J, Siddiqui A, Lapergue B, Piotin M, Turk A, Berkhemer OA, Lingsma H, Majoie CB, Samuels N, Yoo A, Frei D, Zaidat OO, Khatri P, Dippel DW. Abstract WP34: ASPIRE: Aspiration Thrombectomy as the Primary Modality in Endovascular Stroke Treatment: Pooled Analysis of the 3D Stent-Retriever, ASTER, THERAPY, COMPASS and MR CLEAN Trials. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Given the overwhelming evidence for the benefit of stent-retriever thrombectomy, a future trial of primary aspiration thrombectomy (PAT) against best medical therapy (BMT) alone has become unethical and impractical. Therefore, alternative approaches are needed to further investigate the impact of PAT in the outcomes in large vessel occlusion (LVO) strokes. The aim of this project is to assess the effectiveness of PAT plus BMT (including IV t-PA if indicated) compared to BMT alone in patients with anterior circulation LVO strokes.
Methods:
A systematic search of the medical literature and trial registries (EMBASE, Pubmed Medline, Cochrane trial registry, clinical trials.gov and ISRCTN) was conducted to trace randomized clinical trials (RCT) that evaluated PAT as a first treatment approach for LVO strokes. Four prospective RCTs employing aspiration thrombectomy as a primary treatment modality in one arm were identified: THERAPY (n=108; 55 PAT), Penumbra 3D Stent-Retriever (n=198; 100 PAT), ASTER (n=381; 192 PAT) and COMPASS (n=270; 134 PAT). Data from the PAT arms from these four RCTs and controls from the MR CLEAN (n=500; 267 controls) and THERAPY (53 controls) trials will be pooled. Treatment effect on the primary outcome (90-day mRS ordinal shift analysis) will be analyzed with multivariable ordinal regression analysis in the propensity matched dataset, after adjusting for remaining differences in distribution of baseline prognostic factors, to increase power. Adjustments will be made for age, sex, baseline NIHSS, collateral score, pre-treatment ASPECTS, admission glucose levels, time from stroke onset to qualifying imaging. The effect will be expressed as an adjusted common odds ratio, with 95% confidence interval. Treatment effects for secondary outcomes will be estimated in a similar approach, with the appropriate regression method.
Results:
The data will be analyzed by an independent statistical group (Erasmus MC, University Medical Center Rotterdam, the Netherlands). The results will be available and reported at the time of the ISC 2019.
Conclusion:
This pooled data project will provide unique and high-level evidence concerning the effect of aspiration thrombectomy on functional outcome after acute ischemic stroke.
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Affiliation(s)
| | - Rob A van de Graaf
- Erasmus MC, Univ Med Cntr Rotterdam, the Netherlands, Rotterdam, Netherlands
| | - J Mocco
- Neurosurgery, Icahn Sch of Medicine, New York, NY
| | - Adnan Siddiqui
- Neurosurgery, State Univ of New York at Buffalo, Buffalo, NY
| | - Bertrand Lapergue
- Neurology, Université Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Michel Piotin
- Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Aquilla Turk
- Neurosurgery, Med Univ South Carolina, Charleston, SC
| | - Olvert A Berkhemer
- Neurology, Erasmus MC, Univ Med Cntr Rotterdam, and Amsterdam Univ Med Cntr, Rotterdam, Netherlands
| | - Hester Lingsma
- Erasmus MC, Univ Med Cntr Rotterdam, the Netherlands, Rotterdam, Netherlands
| | - Charles B Majoie
- Radiology, Amsterdam Univ Med Cntr, the Netherlands, Amsterdam, Netherlands
| | - Noor Samuels
- Erasmus MC, Univ Med Cntr Rotterdam, the Netherland, Rotterdam, Netherlands
| | - Albert Yoo
- Radiology, Texas Stroke Institute, Dallas, TX
| | | | | | | | - Diederik W Dippel
- Neurology, Erasmus MC, Univ Med Cntr Rotterdam, the Netherlands, Rotterdam, Netherlands
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van de Graaf RA, Roozenbeek B, Chalos V, van Es AC, den Hertog HM, Staals J, van Dijk L, Jenniskens SF, van der Lugt A, Dippel DW. Abstract WP54: MR CLEAN-MED - The Effect of Periprocedural Medication in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke: Heparin, Antiplatelet Agents, Both or Neither. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Rapid endovascular treatment (EVT) in patients with acute ischemic stroke with confirmed proximal intracranial occlusion has been proven safe and effective. Still, many patients do not recover despite recanalization. Yet, it is unknown whether periprocedural antithrombotic medication in patients treated with EVT can improve clinical outcome. The objective of this study is to assess the effect of acetylsalicylic acid (ASA) and unfractionated heparin, alone, or in combination, in patients who undergo EVT.
Methods:
MR CLEAN-MED is a multicenter, prospective, randomized, open-label, blinded-endpoint trial using a 2x3 factorial design. We plan to enroll 1500 patients with a clinical diagnosis of acute ischemic stroke and confirmed intracranial anterior circulation occlusion, who will undergo EVT with or without prior intravenous thrombolysis according to standard care. Study interventions: IV treatment with ASA (300 mg), low dose unfractionated heparin (loading dose of 5000 IU followed by 500 IU/hour x 6 hours) and moderate dose unfractionated heparin (loading dose of 5000 IU followed by 1250 IU/hour x 6 hours). Primary outcome is the score on the modified Rankin Scale 90 days after inclusion in the study. Safety endpoints include the occurrence of symptomatic intracerebral hemorrhage.
Results:
First patient enrolled on January 22nd, 2018. 1 active enrolling site, 17 sites starting up.
Conclusion:
We hypothesize that despite the potentially increased risk of (symptomatic) intracerebral hemorrhage, periprocedural ASA and unfractionated heparin alone or in combination will improve functional outcome of patients with acute ischemic stroke treated with EVT.
Trial Registration Number:
ISRCTN 76741621
Funding:
Dutch Heart Foundation, Dutch Brain Foundation, Stryker
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Affiliation(s)
- Rob A van de Graaf
- Neurology & Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Neurology & Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Vicky Chalos
- Neurology & Radiology and Nuclear Medicine & Public Health, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Adriaan C van Es
- Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | | | - Julie Staals
- Neurology, Maastricht Univ Med Cntr, Maastricht, Netherlands
| | | | | | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Diederik W Dippel
- Neurology & Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
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van de Graaf RA, Chalos V, van Es AC, Emmer BJ, Lycklama à Nijeholt GJ, Schonewille WJ, van der Lugt A, Dippel DW, Roozenbeek B. Abstract TP6: Periprocedural Intravenous Heparin During Endovascular Treatment for Acute Ischemic Stroke: Results From the MR CLEAN Registry. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Intravenous (IV) administration of heparin during endovascular treatment (EVT) for ischemic stroke may improve functional outcome. However, the risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate the use of periprocedural IV heparin in Dutch stroke intervention centers, and to assess its efficacy and safety.
Methods:
Patients registered between March 2014 and June 2016 in the MR CLEAN Registry, including all patients treated with EVT in the Netherlands, were analyzed. We quantified between-center variation and used multilevel logistic and ordinal regression analysis to compare patients treated with and without periprocedural IV heparin, adjusted for center-effects, prognostic factors and time. The primary outcome was functional outcome (modified Rankin Scale) at 90-days. Secondary outcomes were successful recanalization (extended thrombolysis in cerebral infarction ≥ 2B), symptomatic intracerebral hemorrhage (sICH) and mortality at 90-days. To account for possible unobserved confounding by indication we also analyzed the effect of center-preference to administer heparin, defined as percentage of patients treated with heparin in a center, on outcome.
Results:
A total of 1488 patients from 16 centers were analyzed, of which 398 (27%) patients received IV heparin (median dose 5000 IU). There was substantial between-center variability in heparin use (range: 0%-94%). Analysis at center-level showed that functional outcomes were better in centers with higher percentages of heparin administration (acOR 1.07 per 10% more heparin, 95% CI 1.01-1.13). However, there was no significant difference in functional outcome between patients actually treated with and without IV heparin (adjusted common odds ratio (acOR) 1.17, 95% confidence interval (CI) 0.88-1.56), successful recanalization (aOR 1.21, 95% CI 0.87-1.68), sICH (6% vs. 6%; aOR 1.10, 95% CI 0.63-1.94) and mortality (aOR 0.94, 95% CI 0.65-1.35).
Conclusion:
Among patients treated with EVT, substantial between-center variability exists in periprocedural IV heparin use. Periprocedural IV heparin use seems a safe adjunctive therapy to EVT. A randomized trial is needed to to assess the effects of periprocedural IV heparin .
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Affiliation(s)
- Rob A van de Graaf
- Neurology & Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Vicky Chalos
- Neurology & Radiology and Nuclear Medicine & Public Health, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Adriaan C van Es
- Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | - Bart J Emmer
- Radiology, Academic Med Cntr, Amsterdam, Netherlands
| | | | | | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
| | | | - Bob Roozenbeek
- Neurology & Radiology and Nuclear Medicine, Erasmus MC Univ Med Cntr, Rotterdam, Netherlands
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Samuels N, van de Graaf RA, van der Lugt A, van Es AC, Dippel DW, Emmer BJ. The ongoing debate on anesthetic strategies during endovascular treatment: Can local anesthesia solve the puzzle? Int J Stroke 2019; 14:NP1-NP2. [PMID: 30624158 PMCID: PMC6604399 DOI: 10.1177/1747493018823571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Noor Samuels
- 1 Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,2 Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,3 Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- 1 Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,2 Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- 1 Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Cgm van Es
- 1 Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik Wj Dippel
- 2 Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Bart J Emmer
- 4 Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Compagne KCJ, van de Graaf RA, van der Lugt A. Additional Factors Regarding Clinical Outcomes of General Anesthesia and Conscious Sedation for Acute Ischemic Stroke. JAMA Neurol 2018; 75:1151. [PMID: 30014135 DOI: 10.1001/jamaneurol.2018.1844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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van de Graaf RA, van Beusekom HMM, Roozenbeek B. Letter by van de Graaf et al Regarding Article, "Thrombus Neutrophil Extracellular Traps Content Impair tPA-Induced Thrombolysis in Acute Ischemic Stroke". Stroke 2018; 49:e265. [PMID: 29866759 DOI: 10.1161/strokeaha.118.021692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rob A van de Graaf
- Department of Radiology and Nuclear Medicine, Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Bob Roozenbeek
- Department of Radiology and Nuclear Medicine, Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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van de Graaf RA, Samuels N, Mulder MJHL, Eralp I, van Es ACGM, Dippel DWJ, van der Lugt A, Emmer BJ. Conscious sedation or local anesthesia during endovascular treatment for acute ischemic stroke. Neurology 2018; 91:e19-e25. [PMID: 29858471 DOI: 10.1212/wnl.0000000000005732] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/23/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate the effect of conscious sedation (CS) on functional outcome and complication rates after intra-arterial treatment (IAT) for acute ischemic stroke (AIS) compared to the use of local anesthesia (LA) at the puncture site only. METHODS Patients undergoing IAT for AIS with CS or LA in the Erasmus University Medical Center from March 2014 to June 2016 were included for analysis. The primary outcome was the score on the ordinal modified Rankin Scale (mRS). We compared CS to LA by ordinal logistic regression with covariate adjustment using propensity scoring. RESULTS In 146 AIS patients treated with IAT, use of CS was associated with a shift towards worse mRS scores (odds ratio [OR] 0.4 [95% confidence interval (CI) 0.2-0.7]) compared to LA. Mortality after 90 days was higher in the CS group compared to the LA group (OR 2.3 [95% CI 1.0-5.2]). No differences between groups were noted with regard to procedure duration (8 minutes, β = 6.3 [95% CI -7.4 to 20.0]) or occurrence of procedure-related complications (OR 1.3 [95% CI 0.6-2.7]). CONCLUSION CS was associated with poor functional outcome and increased mortality rates compared to LA. Furthermore, CS did not reduce duration of intervention or interventional complications. CS during IAT for AIS is of no benefit if LA is considered safe. CLASSIFICATION OF EVIDENCE This study provides Class II evidence, because of nonrandom allocation, that for patients with AIS undergoing IAT, LA rather than CS improves functional outcome.
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Affiliation(s)
- Rob A van de Graaf
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands.
| | - Noor Samuels
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Maxim J H L Mulder
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Ismail Eralp
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Adriaan C G M van Es
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Diederik W J Dippel
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Aad van der Lugt
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
| | - Bart J Emmer
- From the Departments of Radiology (R.A.v.d.G., N.S., M.J.H.L.M., A.C.G.M.v.E., A.v.d.L., B.J.E.), Neurology (R.A.v.d.G., N.S., M.J.H.L.M., D.W.J.D.), and Anesthesia (I.E.), Erasmus MC, University Medical Center Rotterdam; and the Department of Radiology (B.J.E.), Academic Medical Center, Amsterdam, the Netherlands
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van de Graaf RA, Chalos V, del Zoppo GJ, van der Lugt A, Dippel DWJ, Roozenbeek B. Periprocedural Antithrombotic Treatment During Acute Mechanical Thrombectomy for Ischemic Stroke: A Systematic Review. Front Neurol 2018; 9:238. [PMID: 29713305 PMCID: PMC5911634 DOI: 10.3389/fneur.2018.00238] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/26/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND More than one-third of the patients with ischemic stroke caused by an intracranial large vessel occlusion do not recover to functional independence despite fast and successful recanalization by acute mechanical thrombectomy (MT). This may partially be explained by incomplete microvascular reperfusion. Some antithrombotics, e.g., antiplatelet agents and heparin, may be able to restore microvascular reperfusion. However, antithrombotics may also increase the risk of symptomatic intracranial hemorrhage (sICH). The aim of this review was to assess the potential safety and functional outcome of periprocedural antiplatelet or heparin use during acute MT for ischemic stroke. METHODS We systematically searched PubMed, Embase, Medline, Web of Science, and Cochrane for studies investigating the safety and functional outcome of periprocedural antiplatelet or heparin treatment during acute MT for ischemic stroke. The primary outcome was the risk for sICH. Secondary outcomes were functional independence after 3-6 months (modified Rankin Scale 0-2) and mortality within 6 months. RESULTS 837 studies were identified through the search, of which 19 studies were included. The sICH risks of the periprocedural use of antiplatelets ranged from 6 to 17%, and for heparin from 5 to 12%. Two of four studies reporting relative effects of the use of antithrombotics are pointing toward an increased risk of sICH. Among patients treated with antiplatelet agents, functional independence varied from 23 to 60% and mortality from 18 to 33%. For heparin, this was, respectively, 19-54% and 19-33%. The three studies presenting relative effects of antiplatelets on functional independence showed neutral effects. Both studies reporting relative effects of heparin on functional independence found it to increase this chance. CONCLUSION Randomized controlled trials investigating the effect of periprocedural antithrombotic treatment in MT are lacking. Some observational studies report a slight increase in sICH risk, which may be acceptable because they also suggest a beneficial effect on functional outcome. Therefore, randomized controlled trials are warranted to address the question whether the potentially higher risk of sICH could be outweighed by improved functional outcome.
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Affiliation(s)
- Rob A. van de Graaf
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Gregory J. del Zoppo
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, United States
| | - Aad van der Lugt
- Department of Radiology, 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, Erasmus MC University Medical Center, Rotterdam, Netherlands
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van de Graaf RA, Grüne F, Hoeks SE, ten Raa S, Stolker RJ, Verhagen HJM, van Lier F. One-Year Follow-Up After Hybrid Thoracoabdominal Aortic Repair. Vasc Endovascular Surg 2016; 51:23-27. [DOI: 10.1177/1538574416683755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Compared to open thoracoabdominal aortic aneurysm (TAAA) repair, hybrid repair is thought to be less invasive with better perioperative outcomes. Due to the extent of the operation and long recovery period, studying perioperative results may not be sufficient for evaluation of the true treatment effect. The aim of this study is to evaluate 1-year mortality and morbidity in patients with TAAA undergoing hybrid repair. Methods: In a retrospective cohort study, all medical records of patients undergoing hybrid repair for TAAA at the Erasmus University Medical Center between January 2007 and January 2015 were studied. Primary outcome measures were 30-day and 1-year mortality. Secondary outcome measures included major in-hospital postoperative complications. Results: A total of 15 patients were included. All-cause mortality was 33% (5 of the 15) at 30 days and 60% (9 of the 15) at 1 year. Aneurysm-related mortality was 33% (5 of the 15) and 53% (8 of the 15) at 30-day and 1-year follow-up, respectively, with colon ischemia being the most common cause of death. Major complication rate was high: myocardial infarction in 2 (13%) cases, acute kidney failure in 5 (33%) cases, bowel ischemia in 3 (20%) cases, and spinal cord ischemia in 1 (7%) case. Conclusion: The presumed less invasive nature of hybrid TAAA repair does not seem to result in lower complication rates. The high mortality rate at 30 days continues to rise dramatically thereafter, suggesting that 1-year mortality is a more useful clinical parameter to use in preoperative decision-making for this kind of repair.
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Affiliation(s)
- Rob A. van de Graaf
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Vascular surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank Grüne
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sanne E. Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Vascular surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sander ten Raa
- Department of Vascular surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hence J. M. Verhagen
- Department of Vascular surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
- Both authors contributed equally as a senior author to this work
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Both authors contributed equally as a senior author to this work
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