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Ischemic stroke
Original research
Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke
  1. Sanne J den Hartog1,2,3,
  2. Bob Roozenbeek1,2,
  3. Nikki Boodt1,2,3,
  4. Agnetha A E Bruggeman4,
  5. Adriaan C G M van Es5,
  6. Bart J Emmer4,
  7. Charles B L M Majoie4,
  8. Ido R van den Wijngaard6,7,
  9. Pieter Jan van Doormaal2,
  10. Wim H van Zwam8,
  11. Hester F Lingsma3,
  12. Diederik W J Dippel1
  13. MR CLEAN Registry investigators
    1. 1 Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
    2. 2 Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
    3. 3 Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
    4. 4 Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
    5. 5 Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
    6. 6 Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
    7. 7 Neurology, Leiden University Medical Center, Leiden, The Netherlands
    8. 8 Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
    1. Correspondence to Sanne J den Hartog, Neurology, Erasmus Medical Center, Rotterdam 3000 CA, The Netherlands; s.denhartog{at}erasmusmc.nl

    Abstract

    Background First pass reperfusion (FPR), that is, excellent reperfusion (expanded treatment in cerebral ischemia (eTICI) 2C-3) in one pass, after endovascular treatment (EVT) of an occluded artery in the anterior circulation, is associated with favorable clinical outcome, even when compared with multiple pass excellent reperfusion (MPR). In patients with posterior circulation ischemic stroke (PCS), the same association is expected, but currently unknown. We aimed to assess characteristics associated with FPR and the influence of FPR versus MPR on outcomes in patients with PCS.

    Methods We used data from the MR CLEAN Registry, a prospective observational study. The effect of FPR on 24-hour National Institutes of Health Stroke Scale (NIHSS) score, as percentage reduction, and on modified Rankin Scale (mRS) scores at 3 months, was tested with linear and ordinal logistic regression models.

    Results Of 224 patients with PCS, 45 patients had FPR, 47 had MPR, and 90 had no excellent reperfusion (eTICI <2C). We did not find an association between any of the patient, imaging, or treatment characteristics and FPR. FPR was associated with better NIHSS (−45% (95% CI: −65% to −12%)) and better mRS scores (adjusted common odds ratio (acOR): 2.16 (95% CI: 1.23 to 3.79)) compared with no FPR. Outcomes after FPR were also more favorable compared with MPR, but the effect was smaller and not statistically significant (NIHSS: −14% (95% CI: −51% to 49%), mRS acOR: 1.50 (95% CI: 0.75 to 3.00)).

    Conclusions FPR in patients with PCS is associated with favorable clinical outcome in comparison with no FPR. In comparison with MPR, the effect of FPR was no longer statistically significant. Nevertheless, our data support the notion that FPR should be the treatment target to pursue in every patient treated with EVT.

    • stroke
    • thrombectomy
    • brain
    • intervention

    Data availability statement

    In compliance with the General Data Protection Regulation, source data are not available for other researchers. Information about analytic methods, study materials and scripts of the statistical analyses are available from the corresponding author on reasonable request.

    https://creativecommons.org/licenses/by/4.0/

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

    https://doi.org/10.1136/neurintsurg-2021-017507

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      Data availability statement

      In compliance with the General Data Protection Regulation, source data are not available for other researchers. Information about analytic methods, study materials and scripts of the statistical analyses are available from the corresponding author on reasonable request.

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      Footnotes

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      • Collaborators MR CLEAN Registry investigators: Executive committee: Diederik W.J. Dippel (Department of Neurology, Erasmus MC, University Medical Center); Aad van der Lugt (Department of Radiology, Erasmus MC, University Medical Center); Charles B.L.M. Majoie (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Yvo B.W.E.M. Roos (Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Wim H. van Zwam (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Jelis Boiten (Department of Neurology, Haaglanden MC, the Hague); Jan Albert Vos (Department of Radiology, Sint Antonius Hospital, Nieuwegein). Study coordinators: Ivo G.H. Jansen (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Maxim J.H.L. Mulder (Department of Neurology; Radiology, Erasmus MC, University Medical Center) ;Robert- Jan B. Goldhoorn (Department of Neurology, Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Kars C.J. Compagne (Department of Radiology, Erasmus MC, University Medical Center); Manon Kappelhof (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Josje Brouwer (Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Sanne J. den Hartog (Department of Neurology, Erasmus MC, University Medical Center; Radiology, Erasmus MC, University Medical Center); Wouter H. Hinsenveld (Department of Neurology, Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)). Local principal investigators: Diederik W.J. Dippel (Department of Neurology, Erasmus MC, University Medical Center); Bob Roozenbeek (Department of Neurology, Erasmus MC, University Medical Center); Aad van der Lugt (Department of Radiology, Erasmus MC, University Medical Center); Charles B.L.M. Majoie (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Yvo B.W.E.M. Roos (Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Jonathan M. Coutinho (Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Wouter J. Schonewille (Department of Neurology, Sint Antonius Hospital, Nieuwegein); Jan Albert Vos (Department of Neurology, Sint Antonius Hospital, Nieuwegein); Marieke J.H. Wermer (Department of Neurology, Leiden University Medical Center); Marianne A.A. van Walderveen (Department of Radiology, Leiden University Medical Center); Adriaan C.G.M. van Es (Department of Radiology, Leiden University Medical Center); Julie Staals (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Wim H. van Zwam (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Jeannette Hofmeijer (Department of Neurology, Rijnstate Hospital, Arnhem); Jasper M. Martens (Department of Radiology, Rijnstate Hospital, Arnhem); Geert J. Lycklama à Nijeholt (Department of Radiology, Haaglanden MC, the Hague); Jelis Boiten (Department of Neurology, Haaglanden MC, the Hague); Sebastiaan F. de Bruijn (Department of Neurology, HAGA Hospital, the Hague); Lukas C. van Dijk (Department of Radiology, HAGA Hospital, the Hague); H. Bart van der Worp (Department of Neurology, University Medical Center Utrecht); Rob H. Lo (Department of Radiology, University Medical Center Utrecht); Ewoud J. van Dijk (Department of Neurology, Radboud University Medical Center, Nijmegen); Hieronymus D. Boogaarts (Department of Neurosurgery, Radboud University Medical Center, Nijmegen); J. de Vries (Department of Neurology, Isala Klinieken, Zwolle); Paul L.M. de Kort (Department of Neurology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Julia van Tuijl (Department of Neurology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Jo P. Peluso (Department of Radiology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Puck Fransen (Department of Neurology, Isala Klinieken, Zwolle); Jan S.P. van den Berg (Department of Neurology, Isala Klinieken, Zwolle); Boudewijn A.A.M. van Hasselt (Department of Radiology, Isala Klinieken, Zwolle); Leo A.M. Aerden (Department of Neurology, Reinier de Graaf Gasthuis, Delft); René J. Dallinga (Department of Radiology, Reinier de Graaf Gasthuis, Delft); Maarten Uyttenboogaart (Department of Neurology, University Medical Center Groningen); Omid Eschgi (Department of Radiology, University Medical Center Groningen); Reinoud P.H. Bokkers (Department of Radiology, University Medical Center Groningen); Tobien H.C.M.L. Schreuder (Department of Neurology, Atrium Medical Center, Heerlen); Roel J.J. Heijboer (Department of Radiology, Atrium Medical Center, Heerlen); Koos Keizer (Department of Neurology, Catharina Hospital, Eindhoven); Lonneke S.F. Yo (Department of Radiology, Catharina Hospital, Eindhoven); Heleen M. den Hertog (Department of Neurology, Isala Klinieken, Zwolle); Emiel J.C. Sturm (Department of Neurology, Medisch Spectrum Twente, Enschede;); Paul J.A.M. Brouwers (Department of Neurology, Medisch Spectrum Twente, Enschede). Imaging assessment committee: Charles B.L.M. Majoie (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam) (chair); Wim H. van Zwam (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Aad van der Lugt (Department of Radiology, Erasmus MC, University Medical Center); Geert J. Lycklama à Nijeholt (Department of Radiology, Haaglanden MC, the Hague); Marianne A.A. van Walderveen (Department of Radiology, Leiden University Medical Center); Marieke E.S. Sprengers (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Sjoerd F.M. Jenniskens (Department of Radiology, Radboud University Medical Center, Nijmegen); René van den Berg (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Albert J. Yoo (Department of Radiology, Texas Stroke Institute, Texas, United States of America); Ludo F.M. Beenen (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Alida A. Postma (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Stefan D. Roosendaal (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Bas F.W. van der Kallen (Department of Radiology, Haaglanden MC, the Hague); Ido R. van den Wijngaard (Department of Radiology, Haaglanden MC, the Hague); Adriaan C.G.M. van Es (Department of Radiology, Leiden University Medical Center); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Jasper M. Martens (Department of Radiology, Rijnstate Hospital, Arnhem); Lonneke S.F. Yo (Department of Radiology, Catharina Hospital, Eindhoven); Jan Albert Vos (Department of Radiology, Sint Antonius Hospital, Nieuwegein); Joost Bot (Department of Radiology, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam); Pieter Jan van Doormaal (Department of Radiology, Erasmus MC, University Medical Center); Anton Meijer (Department of Radiology, Radboud University Medical Center, Nijmegen); Elyas Ghariq (Department of Radiology, Haaglanden MC, the Hague); Reinoud P.H. Bokkers (Department of Radiology, University Medical Center Groningen); Marc P. van Proosdij (Department of Radiology, Noordwest Ziekenhuisgroep, Alkmaar); G. Menno Krietemeijer (Department of Radiology, Catharina Hospital, Eindhoven); Jo P. Peluso (Department of Radiology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Hieronymus D. Boogaarts (Department of Neurosurgery, Radboud University Medical Center, Nijmegen); Rob Lo (Department of Radiology, University Medical Center Utrecht); Dick Gerrits (Department of Radiology, Medisch Spectrum Twente, Enschede); Wouter Dinkelaar (Department of Radiology, Albert Schweitzer Hospital, Dordrecht); Auke P.A. Appelman (Department of Radiology, University Medical Center Groningen); Bas Hammer (Department of Radiology, HAGA Hospital, the Hague); Sjoert Pegge (Department of Radiology, Radboud University Medical Center, Nijmegen); Anouk van der Hoorn (Department of Radiology, University Medical Center Groningen); Saman Vinke (Department of Neurosurgery, Radboud University Medical Center, Nijmegen); Sandra Cornelissen (Radiology, Erasmus MC, University Medical Center); Christiaan van der Leij (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Rutger Brans (Department of Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)). Writing committee: Diederik W.J. Dippel (Department of Neurology, Erasmus MC, University Medical Center) (chair); Aad van der Lugt (Radiology, Erasmus MC, University Medical Center); Charles B.L.M. Majoie (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Yvo B.W.E.M. Roos (Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Wim H. van Zwam (Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Geert J. Lycklama à Nijeholt (Department of Radiology, Haaglanden MC, the Hague); Jelis Boiten (Neurology, Haaglanden MC, the Hague); Jan Albert Vos (Radiology, Sint Antonius Hospital, Nieuwegein); Wouter J. Schonewille (Department of Neurology, Sint Antonius Hospital, Nieuwegein); Jeannette Hofmeijer (Department of Neurology, Rijnstate Hospital, Arnhem); Jasper M. Martens (Radiology, Rijnstate Hospital, Arnhem); H. Bart van der Worp (Department of Neurology, University Medical Center Utrecht); Rob H. Lo (Radiology, University Medical Center Utrecht). Adverse event committee: Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)) (chair); Jeannette Hofmeijer (Department of Neurology, Rijnstate Hospital, Arnhem); H. Zwenneke Flach (Department of Radiology, Isala Klinieken, Zwolle). Trial methodologist: Hester F. Lingsma (Department of Public Health, Erasmus MC, University Medical Center); Research nurses / local trial coordinators: Naziha el Ghannouti (Department of Neurology, Erasmus MC, University Medical Center); Martin Sterrenberg (Department of Neurology, Erasmus MC, University Medical Center); Wilma Pellikaan (Department of Neurology, Sint Antonius Hospital, Nieuwegein); Rita Sprengers (Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Marjan Elfrink (Department of Neurology, Rijnstate Hospital, Arnhem); Michelle Simons (Department of Neurology, Rijnstate Hospital, Arnhem); Marjolein Vossers (Department of Radiology, Rijnstate Hospital, Arnhem); Joke de Meris (Department of Neurology, Haaglanden MC, the Hague); Tamara Vermeulen (Department of Neurology, Haaglanden MC, the Hague); Annet Geerlings (Department of Neurology, Radboud University Medical Center, Nijmegen); Gina van Vemde (Department of Neurology, Isala Klinieken, Zwolle); Tiny Simons (Department of Neurology, Atrium Medical Center, Heerlen); Gert Messchendorp (Department of Neurology, University Medical Center Groningen); Nynke Nicolaij (Department of Neurology, University Medical Center Groningen); Hester Bongenaar (Department of Neurology, Catharina Hospital, Eindhoven); Karin Bodde (Department of Neurology, Reinier de Graaf Gasthuis, Delft); Sandra Kleijn (Department of Neurology, Medisch Spectrum Twente, Enschede); Jasmijn Lodico (Department of Neurology, Medisch Spectrum Twente, Enschede); Hanneke Droste (Department of Neurology, Medisch Spectrum Twente, Enschede); Maureen Wollaert (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Sabrina Verheesen (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); D. Jeurrissen ((Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM))); Erna Bos (Department of Neurology, Leiden University Medical Center); Yvonne Drabbe (Department of Neurology, HAGA Hospital, the Hague); Michelle Sandiman (Department of Neurology, HAGA Hospital, the Hague); Nicoline Aaldering (Department of Neurology, Rijnstate Hospital, Arnhem); Berber Zweedijk (Department of Neurology, University Medical Center Utrecht); Jocova Vervoort (Department of Neurology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Eva Ponjee (Department of Neurology, Isala Klinieken, Zwolle); Sharon Romviel (Department of Neurology, Radboud University Medical Center, Nijmegen); Karin Kanselaar (Department of Neurology, Radboud University Medical Center, Nijmegen); Denn Barning (Department of Radiology, Leiden University Medical Center). Clinical/imaging data aquisition: Esmee Venema (Department of Public Health, Erasmus MC, University Medical Center); Vicky Chalos (Department of Neurology, Public Health, Erasmus MC, University Medical Center); Ralph R. Geuskens (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Tim van Straaten (Department of Neurology, Radboud University Medical Center, Nijmegen); Saliha Ergezen (Department of Neurology, Erasmus MC, University Medical Center); Roger R.M. Harmsma (Department of Neurology, Erasmus MC, University Medical Center); Daan Muijres (Department of Neurology, Erasmus MC, University Medical Center); Anouk de Jong (Department of Neurology, Erasmus MC, University Medical Center); Olvert A. Berkhemer (Department of Neurology, Erasmus MC, University Medical Center; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam; Radiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Anna M.M. Boers (Department of Radiology and Nuclear Medicine, Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); J. Huguet (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); P.F.C. Groot (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Marieke A. Mens (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Katinka R. van Kranendonk (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Kilian M. Treurniet (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Manon L. Tolhuisen (Department of Radiology and Nuclear Medicine, Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); Heitor Alves (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Annick J. Weterings (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Eleonora L.F. Kirkels (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Eva J.H.F. Voogd (Department of Neurology, Rijnstate Hospital, Arnhem); Lieve M. Schupp (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Sabine L. Collette (Department of Neurology, Radiology, University Medical Center Groningen); Adrien E.D. Groot (Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Natalie E. LeCouffe (Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Praneeta R. Konduri (Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); Haryadi Prasetya (Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); Nerea Arrarte-Terreros (Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); Lucas A. Ramos (Biomedical Engineering & Physics, Amsterdam UMC, University of Amsterdam, Amsterdam); Nikki Boodt (Department of Neurology, Radiology, Public Health, Erasmus MC, University Medical Center); Anne F.A.V Pirson (Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)); Agnetha A.E. Bruggeman (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam).

      • Contributors SJdH monitored data collection for the whole trial, wrote the statistical analysis plan, cleaned and analyzed the data, and drafted and revised the paper. NB and AAEB collected data and revised the draft paper. BR, ACGMvE, BJE, CBLMM, WHvZ, IRvdW, PJvD, and HFL revised the draft paper. DWJD wrote the statistical analysis plan and drafted and revised the paper.

      • Funding The MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke) was partly funded by Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN), Erasmus MC, University Medical Center, Maastricht University Medical Center, and Amsterdam University Medical Center.

      • Competing interests DWJD reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health, and unrestricted grants from Penumbra Inc., Stryker European Operations BV, Medtronic, Thrombolytic Science, LLC, and Cerenovus for research, all paid to his institution. CBLMM reports grants from CVON/Dutch Heart Foundation, European Commission, TWIN Foundation, Dutch Health Evaluation Program, and Stryker, paid to his institution and is a minority shareholder of NICO.LAB. WHvZ received consultation fees from Stryker and Cerenovus, paid to his institution. PJvD received consultation fees from Stryker, paid to his institution.

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

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