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Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry
  1. Faysal Benali1,2,
  2. Manon Kappelhof3,
  3. Johanna Ospel4,
  4. Aravind Ganesh2,
  5. Rosalie V McDonough2,5,
  6. Alida A Postma1,
  7. Robert-Jan Berend Goldhoorn6,
  8. Charles B L M Majoie3,
  9. Ido van den Wijngaard7,
  10. Hester F Lingsma8,
  11. Jan Albert Vos9,
  12. Robert J van Oostenbrugge6,
  13. Wim H van Zwam1,
  14. Mayank Goyal2
  15. on behalf of MR CLEAN Registry investigators
  1. 1 Radiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
  2. 2 Departments of Clinical Neurosciences and Community Health Sciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  3. 3 Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
  4. 4 Department of Radiology, University Hospital Basel, Basel, Switzerland
  5. 5 Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
  6. 6 Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
  7. 7 Neurology, Haaglanden Medical Center (HMC), The Hague, The Netherlands
  8. 8 Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
  9. 9 Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
  1. Correspondence to Dr Mayank Goyal, Diagnostic Imaging, University of Calgary, Calgary, AB T2N 1N4, Canada; mgoyal2412{at}


Background Pre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence exists for EVT in those patients. We aimed to investigate the safety and benefit of EVT in pre-stroke patients with mRS score 3.

Methods We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in the Netherlands (MR CLEAN) Registry. All patients treated with EVT for anterior circulation AIS with pre-stroke mRS 3 were included. We assessed causes for dependence and compared patients with successful reperfusion (defined as expanded Thrombolysis in Cerebral Ischemia scale (eTICI) 2b–3) to patients without successful reperfusion. We used regression analyses with pre-specified adjustments. Our primary outcome was 90-day mRS 0–3 (functional improvement or return to baseline).

Results A total of 192 patients were included, of whom 82 (43%) had eTICI <2b and 108 (56%) eTICI ≥2b. The median age was 80 years (IQR 73–87). Fifty-one of the 192 patients (27%) suffered from previous stroke and 36/192 (19%) had cardiopulmonary disease. Patients with eTICI ≥2b more often returned to their baseline functional state or improved (n=26 (26%) vs n=15 (19%); adjusted odds ratio (aOR) 2.91 (95% CI 1.08 to 7.82)) and had lower mortality rates (n=49 (49%) vs n=50 (64%); aOR 0.42 (95% CI 0.19 to 0.93)) compared with patients with eTICI <2b.

Conclusions Although patients with AIS with pre-stroke mRS 3 comprise a heterogenous group of disability causes, we observed improved outcomes when patients achieved successful reperfusion after EVT.

  • Stroke
  • Thrombectomy
  • Brain

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @draravindganesh, @rosevmcd

  • Collaborators Diederik W.J. Dippel; Aad van der Lugt; Charles B.L.M. Majoie; Yvo B.W.E.M. Roos; Robert J. van Oostenbrugge; Wim H. van Zwam; Jelis Boiten; Jan Albert Vos

  • Contributors FB collected and analyzed the data and wrote the manuscript. MK analyzed the data and revised the manuscript. JO, AG and RVM revised the manuscript. MG and WHvZ created the hypothesis and research question. All co-authors assisted in revising the manuscript. MG is the guarantor.

  • Funding The MR CLEAN Registry was supported by a grant from the Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN).

  • Competing interests WHvZ: Speaker fees from Stryker, Cerenovus, NicoLab (all paid to institution). MG: consultant (Medtronic, Stryker, Mentice, Microvention), license agreement (GE Healthcare, Microvention). AG: reports membership of editorial boards of Neurology, Neurology: Clinical Practice, and Stroke; research support from the Canadian Institutes of Health Research, Canadian Cardiovascular Society, Campus Alberta Neuroscience, and Alberta Innovates; consultation fees from MD Analytics, CTC Communications Corp, MyMedicalPanel, and Atheneum; stock options from SnapDx,, and Advanced Health Analytics (AHA Health Ltd); and a provisional patent application for a system for delivery of remote ischemic conditioning or other cuff-based therapies. JO: consultant (NICO.Lab). CBLM: grants from TWIN Foundation during the conduct of the study (paid to institution); grants from CVON/Dutch Heart Foundation, grants from European Commission, grants from Health Evaluation Netherlands, grants from Stryker outside the submitted work (paid to institution); and is a shareholder of Nico-lab.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.