Intra-arterial thrombolytics during endovascular thrombectomy for acute ischaemic stroke in the MR CLEAN Registry

Introduction The efficacy and safety of local intra-arterial(IA)thrombolytics during endovascular thrombectomy(EVT)for large-vessel occlusions is uncertain.We analysed how often IA thrombolytics were administered in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands(MR CLEAN)Registry,whether it was associated with improved functional outcome and assessed technical and safety outcomes compared with EVT without IA thrombolytics.Methods In this observational study,we included patients undergoing EVT for an acute ischaemic stroke in the anterior circulation from the MR CLEAN Registry(March 2014-November 2017).The primary endpoint was favourable functional outcome,defined as an modified Rankin Scale score≤2 at 90 days.Secondary endpoints were reperfusion status,early neurological recovery and symptomatic intracranial haemorrhage(sICH).Subgroup analyses for IA thrombolytics as primary versus adjuvant revascularisation attempt were performed.Results Of the 2263 included patients,95(4.2%)received IA thrombolytics during EVT.The IA thrombolytics administered were urokinase(median dose,250000 IU(IQR,193750-250000))or alteplase(median dose,20 mg(IQR,12-20)).No association was found between IA thrombolytics and favourable functional outcome(adjusted OR(aOR),1.16;95%CI 0.71 to 1.90).Successful reperfusion was less often observed in those patients treated with IA thrombolytics(aOR,0.57;95%CI 0.36 to 0.90).The odds of sICH(aOR,0.82;95%CI 0.32 to 2.10)and early neurological recovery were comparable between patients treated with and without IA thrombolytics.For primary and adjuvant revascularisation attempts,IA thrombolytics were more often administered for proximal than for distal occlusions.Functional outcomes were comparable for patients receiving IA thrombolytics as a primary versus adjuvant revascularisation attempt.Conclusion Local IA thrombolytics were rarely used in the MR CLEAN Registry.In the relatively small study sample,no statistical difference was observed between groups in the rate of favourable functional outcome or sICH.Patients whom required and underwent IA thrombolytics were patients less likely to achieve successful reperfusion,probably due to selection bias.

Endovascular treatment in anterior circulation stroke beyond 6.5 hours after onset or time last seen well:results from the MR CLEAN Registry

Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment(EVT)for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well.However,outcomes after EVT in these late window patients without perfusion imaging are largely unknown.We assessed their characteristics and outcomes in routine clinical practice.Methods The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry,a prospective,multicentre study in the Netherlands,included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017.CT perfusion was no standard imaging modality.We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age,prestroke modified Rankin Scale(mRS),National Institutes of Health Stroke Scale,Alberta Stroke Programme Early CT Score(ASPECTS),collateral status,location of occlusion and treatment with intravenous thrombolysis.Outcomes included 3-month mRS score,functional independence(defined as mRS 0-2),and death.Results Of 3264 patients who underwent EVT,106(3.2%)were treated beyond 6.5 hours(median 8.5,IQR 6.9-10.6),of whom 93(87.7%)had unknown time of stroke onset.CT perfusion was not performed in 87/106(80.2%)late window patients.Late window patients were younger(mean 67 vs 70 years,p<0.04)and had slightly lower ASPECTS(median 8 vs 9,p<0.01),but better collateral status(collateral score 2-3:68.3%vs 57.7%,p=0.03).No differences were observed in proportions of functional independence(43.3%vs 40.5%,p=0.57)or death(24.0%vs 28.9%,p=0.28).After matching,outcomes remained similar(adjusted common OR for 1 point improvement in mRS 1.04,95%CI 0.56 to 1.93).Conclusions Without the use of CT perfusion selection criteria,EVT in the 6.5-24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics.randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window.

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke:results from the MR CLEAN Registry

Background The optimal management of ipsilateral extracranial internal carotid artery(ICA)stenosis during endovascular treatment(EVT)is unclear.We compared the outcomes of two different strategies:EVT with vs without carotid artery stenting(CAS).Methods In this observational study,we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of≥50%or occlusion of presumed atherosclerotic origin,from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands(MR CLEAN)Registry(2014-2017).The primary endpoint was a good functional outcome at 90 days,defined as a modified Rankin Scale score≤2.Secondary endpoints were successful intracranial reperfusion,new clot in a different vascular territory,symptomatic intracranial haemorrhage,recurrent ischaemic stroke and any serious adverse event.Results Of the 433 included patients,169(39%)underwent EVT with CAS.In 123/168(73%)patients,CAS was performed before intracranial thrombectomy.In 42/224(19%)patients who underwent EVT without CAS,a deferred carotid endarterectomy or CAS was performed.EVT with and without CAS were associated with similar proportions of good functional outcome(47%vs 42%,respectively;adjusted OR(aOR),0.90;95%CI,0.50 to 1.62).There were no major differences between the groups in any of the secondary endpoints,except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group(aOR,2.96;95%CI,1.07 to 8.21).Conclusions Functional outcomes were comparable after EVT with and without CAS.CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.

急性缺血性卒中动脉内治疗的患者选择：两项随机试验研发和验证的一个临床决策工具

目的利用临床决策工具预测个体治疗的疗效，以改善急性卒中血管内治疗的患者选择。方法用2个随机对照临床试验的数据建立多变量回归模型。背景荷兰的16家医院（检测组）和美国、加拿大、澳大利亚、欧洲的58家医院（验证组）。