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Original research
Predictors of poor outcome despite successful endovascular treatment for ischemic stroke: results from the MR CLEAN Registry
  1. Rob A van de Graaf1,2,
  2. Noor Samuels1,2,3,
  3. Vicky Chalos1,2,3,
  4. Geert J Lycklama a Nijeholt4,
  5. Heleen van Beusekom5,
  6. Albert J Yoo6,
  7. Wim H van Zwam7,
  8. Charles B L M Majoie8,
  9. Yvo B W E M Roos9,
  10. Pieter Jan van Doormaal1,
  11. Wagih Ben Hassen10,
  12. Aad van der Lugt1,
  13. Diederik W J Dippel2,
  14. Hester F Lingsma3,
  15. Adriaan C G M van Es11,
  16. Bob Roozenbeek1,2
  17. MR CLEAN Registry investigators
    1. 1Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
    2. 2Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
    3. 3Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    4. 4Radiology, HMC Westeinde, Den Haag, Zuid-Holland, The Netherlands
    5. 5Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    6. 6Neurointervention, Texas Stroke Institute, Plano, Texas, USA
    7. 7Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
    8. 8Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
    9. 9Neurology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
    10. 10Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
    11. 11Radiology and Nuclear Medicine, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
    1. Correspondence to Rob A van de Graaf, Radiology & Nuclear Medicine and Neurology, Erasmus Medical Center, 3015 GD Rotterdam, Zuid-Holland, The Netherlands; r.a.vandegraaf{at}erasmusmc.nl

    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.

    • stroke
    • thrombectomy
    • intervention

    Data availability statement

    No data are available. Data cannot be made available, as no patient approval has been obtained for sharing coded data. However, R syntax and output files of the analyses will be made available on request.

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    Data availability statement

    No data are available. Data cannot be made available, as no patient approval has been obtained for sharing coded data. However, R syntax and output files of the analyses will be made available on request.

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    Footnotes

    • RAvdG and NS contributed equally.

    • Collaborators MR CLEAN Registry investigators: Robert J van Oostenbrugge; Jelis Boiten; Jan Albert Vos; Ivo GH Jansen; Maxim JHL Mulder; Robert-Jan B Goldhoorn; Kars CJ Compagne; Manon Kappelhof; Josje Brouwer; Sanne J den Hartog; Wouter H Hinsenveld; Bart J Emmer; Jonathan M Coutinho; Wouter J Schonewille; Marieke JH Wermer; Marianne AA van Walderveen; Julie Staals; Jeannette Hofmeijer; Jasper M Martens; Sebastiaan F de Bruijn; Lukas C van Dijk; H Bart van der Worp; Rob H Lo; Ewoud J van Dijk; Hieronymus D Boogaarts; J de Vries; Paul LM de Kort; Julia van Tuijl; Jo P Peluso; Puck Fransen; Jan SP van den Berg; Boudewijn AAM van Hasselt; Leo AM Aerden; René J Dallinga; Maarten Uyttenboogaart; Omid Eschgi; Reinoud PH Bokkers; Tobien HCML Schreuder; Roel JJ Heijboer; Koos Keizer; Lonneke SF Yo; Heleen M den Hertog; Emiel JC Sturm; Paul JAM Brouwers; Marieke ES Sprengers; Sjoerd FM Jenniskens; René van den Berg; Ludo FM Beenen; Alida A Postma; Stefan D Roosendaal; Bas FW van der Kallen; Ido R van den Wijngaard; Joost Bot; Anton Meijer; Elyas Ghariq; Marc P van Proosdij; G Menno Krietemeijer; Rob Lo; Dick Gerrits; Wouter Dinkelaar; Auke PA Appelman; Bas Hammer; Sjoert Pegge; Anouk van der Hoorn; Saman Vinke; H Zwenneke Flach; Naziha el Ghannouti; Martin Sterrenberg; Corina Puppels; Wilma Pellikaan; Rita Sprengers; Marjan Elfrink; Michelle Simons; Marjolein Vossers; Joke de Meris; Tamara Vermeulen; Annet Geerlings; Gina van Vemde; Tiny Simons; Cathelijn van Rijswijk; Gert Messchendorp; Nynke Nicolaij; Hester Bongenaar; Karin Bodde; Sandra Kleijn; Jasmijn Lodico; Hanneke Droste; Maureen Wollaert; Sabrina Verheesen; D Jeurrissen; Erna Bos; Yvonne Drabbe; Michelle Sandiman; Nicoline Aaldering; Berber Zweedijk; Mostafa Khalilzada; Jocova Vervoort; Eva Ponjee; Sharon Romviel; Karin Kanselaar; Denn Barning; Esmee Venema; Ralph R Geuskens; Tim van Straaten; Saliha Ergezen; Roger RM Harmsma; Daan Muijres; Anouk de Jong; Olvert A Berkhemer; Anna MM Boers; J Huguet; PFC Groot; Marieke A Mens; Katinka R van Kranendonk; Kilian M Treurniet; Manon L Tolhuisen; Heitor Alves; Annick J Weterings; Eleonora LF Kirkels; Eva JHF Voogd; Lieve M Schupp; Sabine Collette; Adrien ED Groot; Natalie E LeCouffe; Praneeta R Konduri; Haryadi Prasetya; Nerea Arrarte-Terreros; Lucas A Ramos.

    • Contributors RAvdG, NS, and BR had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: RAvdG, NS, VC, HFL, BR. Acquisition, analysis, or interpretation of data: RAvdG, NS, VC, GJLaN, HvB, AJY, WHvZ, CBLM, YBWR, PJVD, WBH, AvdL, DWJD; HFL, ACGvE, BR. Drafting of the manuscript: RAvdG, NS, VC, BR. Critical revision of the manuscript for important intellectual content: GJLaN, HvB, AJY, WHvZ, CBLM, YBWR, PJVDL, WBH, AvdL, DWJD; HFL, ACGvE. Statistical analysis: RAvdG, NS, VC, HFL, BR. Study supervision: BR, DWJD, AvdL.

    • Funding The authors received no funding for this study. The MR CLEAN Registry is partially funded by unrestricted grants from Toegepast Wetenschappelijk Instituut voor Neuromodulatie, Twente University (TWIN), Erasmus MC University Medical Center, Maastricht University Medical Center, and Amsterdam UMC.

    • Disclaimer The funding sources had no role in study design, patient enrolment, data collection, analysis, writing of the manuscript, approval of the manuscript, and decision to submit the manuscript for publication.

    • 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, Stryker European Operations BV, Medtronic, Thrombolytic Science, and Cerenovus for research, all paid to the institution. AvdL reports funding from the Dutch Heart Foundation, Dutch Brain Foundation, Stryker, Angiocare BV, Medtronic/Covidien/EV3, MEDAC GmbH/LAMEPRO, Penumbra, and Top Medical Concentric, all paid to the institution. CBLMM reports funding from CVON/Dutch Heart Foundation, Stryker, Health Evaluation Netherlands, all paid to the institution, and is a shareholder of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis. YBWR reports funding from CVON/Dutch Heart Foundation, Stryker, Health Evaluation Netherlands, all paid to the institution, and is a shareholder of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis.

    • 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.

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