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Original research
Endovascular treatment for isolated posterior cerebral artery occlusion stroke in the MR CLEAN registry
  1. Josje Brouwer1,
  2. Saliha Ergezen2,
  3. Maxim Johan Heymen Laurence Mulder3,
  4. Geert J Lycklama a Nijeholt4,
  5. Adriaan C G M van Es5,
  6. Aad van der Lugt6,
  7. Diederik W J Dippel3,
  8. Charles B L M Majoie7,
  9. Yvo B W E M Roos1,
  10. J M Coutinho1,
  11. Bart J Emmer7
  12. on behalf of the MR CLEAN Registry investigators
    1. 1Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
    2. 2Department of Intensive care/Neurosurgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
    3. 3Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
    4. 4Department of Radiology and Nuclear Medicine, Haaglanden MC, The Hague, The Netherlands
    5. 5Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
    6. 6Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
    7. 7Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
    1. Correspondence to Dr Bart J Emmer, Department of Radiology, Amsterdam University Medical Centres, Amsterdam, Netherlands; b.j.emmer{at}amsterdamumc.nl

    Abstract

    Background Endovascular treatment (EVT) is standard of care in anterior circulation large vessel occlusions. In posterior circulation occlusions, data on EVT in isolated posterior cerebral artery (PCA) occlusions are limited, although PCA occlusions can cause severe neurological deficit.

    Objective To describe in a prospective study the clinical manifestations, outcomes, and safety of EVT in isolated PCA occlusions.

    Methods We used data (2014–2017) from the MR CLEAN Registry, a nationwide, prospective cohort of EVT-treated patients in the Netherlands. We included patients with acute ischemic stroke (AIS) due to an isolated PCA occlusion on CT angiography. Patients with concurrent occlusion of the basilar artery were excluded. Outcomes included change in National Institutes of Health Stroke Scale (ΔNIHSS) score, modified Rankin Scale (mRS) score 0–3 after 90 days, mortality, expanded Thrombolysis in Cerebral Infarction (eTICI), and periprocedural complications.

    Results Twenty (12%) of 162 patients with posterior circulation occlusions had an isolated PCA occlusion. Median age was 72 years; 13 (65%) were women. Median baseline NIHSS score was 13 (IQR 5–21). Six (30%) patients were comatose. Twelve patients (60%) received IVT. Median ΔNIHSS was −4 (IQR −11–+1). At follow-up, nine patients (45%) had mRS score 0–3. Seven (35%) died. eTICI 2b-3 was achieved in 13 patients (65%). Nine patients (45%) had periprocedural complications. No symptomatic intracranial hemorrhages (sICH) occurred.

    Conclusions EVT should be considered in selected patients with AIS with an isolated PCA occlusion, presenting with moderate–severe neurological deficits, as EVT was technically feasible in most of our patients and about half had good clinical outcome. In case of lower NIHSS score, a more conservative approach seems warranted, since periprocedural complications are not uncommon. Nonetheless, EVT seems reasonably safe considering the absence of sICH in our study.

    • stroke
    • thrombectomy
    • posterior fossa

    Data availability statement

    Data may be obtained from a third party and are not publicly available. The data of the study cannot be made available to other researchers, as Dutch law prohibits data sharing when no patient approval was obtained for sharing coded data. However, syntax or output files of the statistical analyses may be made available for academic purposes upon reasonable request.

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. The data of the study cannot be made available to other researchers, as Dutch law prohibits data sharing when no patient approval was obtained for sharing coded data. However, syntax or output files of the statistical analyses may be made available for academic purposes upon reasonable request.

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    Footnotes

    • Collaborators MR CLEAN Registry investigators. Executive committee: Diederik W.J. Dippel (Department of Neurology, Erasmus MC University Medical Center); 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+; School for Cardiovascular Diseases Maastricht (CARIM)); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM)); Jelis Boiten (Neurology, Haaglanden MC, the Hague); Jan Albert Vos (Radiology, Sint Antonius Hospital, Nieuwegein). Study coordinators: Ivo G.H. Jansen (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 & Nuclear Medicine; School for Cardiovascular Diseases Maastricht (CARIM)); Kars C.J. Compagne (Radiology, Erasmus MC University Medical Center); Manon Kappelhof (Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Josje Brouwer (Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Sanne J. den Hartog (Department of Neurology; Radiology; Public Health, Erasmus MC University Medical Center); Wouter H. Hinsenveld (Department of Neurology; Radiology & Nuclear Medicine, Maastricht University Medical Center+). 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 (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); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Jonathan M. Coutinho (Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam); Wouter J. Schonewille (Department of Neurology, Sint Antonius Hospital, Nieuwegein); Jan Albert Vos (Radiology, Sint Antonius Hospital, Nieuwegein); Marieke J.H. Wermer (Department of Neurology, Leiden University Medical Center); Marianne A.A. van Walderveen (Radiology, Leiden University Medical Center); Adriaan C.G.M. van Es (Radiology, Leiden University Medical Center); Julie Staals (Department of Neurology, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM)); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM)); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM)); Jeannette Hofmeijer (Department of Neurology, Rijnstate Hospital, Arnhem); Jasper M. Martens (Radiology, Rijnstate Hospital, Arnhem); Geert J. Lycklama à Nijeholt (Department of Radiology, Haaglanden MC, the Hague); Jelis Boiten (Neurology, Haaglanden MC, the Hague); Sebastiaan F. de Bruijn (Department of Neurology, HAGA Hospital, the Hague); Lukas C. van Dijk (Radiology, HAGA Hospital, the Hague); H. Bart van der Worp (Department of Neurology, University Medical Center Utrecht); Rob H. Lo (Radiology, University Medical Center Utrecht); Ewoud J. van Dijk (Department of Neurology, Radboud University Medical Center, Nijmegen); Hieronymus D. Boogaarts (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 (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 (Radiology, Isala Klinieken, Zwolle); Leo A.M. Aerden (Department of Neurology, Reinier de Graaf Gasthuis, Delft); René J. Dallinga (Radiology, Reinier de Graaf Gasthuis, Delft); Maarten Uyttenboogaart (Department of Neurology, University Medical Center Groningen); Omid Eschgi (Radiology, University Medical Center Groningen); Reinoud P.H. Bokkers (Radiology, University Medical Center Groningen); Tobien H.C.M.L. Schreuder (Department of Neurology, Atrium Medical Center, Heerlen); Roel J.J. Heijboer (Radiology, Atrium Medical Center, Heerlen); Koos Keizer (Department of Neurology, Catharina Hospital, Eindhoven); Lonneke S.F. Yo (Radiology, Catharina Hospital, Eindhoven); Heleen M. den Hertog (Department of Neurology, Isala Klinieken, Zwolle); Emiel J.C. Sturm (Radiology, 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 (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM)); Aad van der Lugt (Radiology, Erasmus MC University Medical Center); Geert J. Lycklama à Nijeholt (Department of Radiology, Haaglanden MC, the Hague); Marianne A.A. van Walderveen (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 (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 (Radiology & Nuclear Medicine, Maastricht University Medical Center+; MHeNs School for Mental Health and Neuroscience, Maastricht, the Netherlands); 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 (Radiology, Leiden University Medical Center); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam); Jasper M. Martens (Radiology, Rijnstate Hospital, Arnhem); Lonneke S.F. Yo (Radiology, Catharina Hospital, Eindhoven); Jan Albert Vos (Radiology, Sint Antonius Hospital, Nieuwegein); Joost Bot (Department of Radiology, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam); Pieter-Jan van Doormaal (Radiology, Erasmus MC University Medical Center); Anton Meijer (Radiology, Radboud University Medical Center, Nijmegen); Elyas Ghariq (Department of Radiology, Haaglanden MC, the Hague); Reinoud P.H. Bokkers (Radiology, University Medical Center Groningen); Marc P. van Proosdij (Department of Radiology, Noordwest Ziekenhuisgroep, Alkmaar); G. Menno Krietemeijer (Radiology, Catharina Hospital, Eindhoven); Jo P. Peluso (Radiology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Hieronymus D. Boogaarts (Neurosurgery, Radboud University Medical Center, Nijmegen); Rob Lo (Radiology, University Medical Center Utrecht); Wouter Dinkelaar (Department of Radiology, Albert Schweitzer Hospital, Dordrecht); Auke P.A. Appelman (Radiology, University Medical Center Groningen); Bas Hammer (Radiology, HAGA Hospital, the Hague); Sjoert Pegge (Radiology, Radboud University Medical Center, Nijmegen); Anouk van der Hoorn (Radiology, University Medical Center Groningen); Saman Vinke (Neurosurgery, Radboud University Medical Center, Nijmegen); Sandra Cornelissen (Radiology, Erasmus MC University Medical Center); Christiaan van der Leij (Radiology & Nuclear Medicine, Maastricht University Medical Center+); Rutger Brans (Radiology & Nuclear Medicine, Maastricht University Medical Center+). 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+; School for Cardiovascular Diseases Maastricht (CARIM)); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases 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+; School for Cardiovascular Diseases Maastricht (CARIM)) (chair); Jeannette Hofmeijer (Department of Neurology, Rijnstate Hospital, Arnhem); H. Zwenneke Flach (Radiology, Isala Klinieken, Zwolle). Trial methodologist: Hester F. Lingsma (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 (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 (Radiology, Rijnstate Hospital, Arnhem); Joke de Meris (Neurology, Haaglanden MC, the Hague); Tamara Vermeulen (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+); Sabrina Verheesen (Department of Neurology, Maastricht University Medical Center+); D. Jeurrissen (Department of Neurology, Maastricht University Medical Center+); 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 (Radiology, Leiden University Medical Center). Clinical/imaging data acquisition: Esmee Venema (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 & Nuclear Medicine, Maastricht University Medical Center+); 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. Groot4; 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+); Agnetha A.E. Bruggeman (Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam)

    • Contributors AvdL, DWJD, CBLMM, and YBWEMR designed the study and participated in the data collection and monitoring of the MR CLEAN Registry. JB and MJHLM monitored data collection for the MR CLEAN Registry as study coordinators. JB and BJE wrote the statistical analysis plan and developed this study. BJE assessed the imaging. JB and BJE cleaned and analyzed the data, and JB wrote the first draft. BJE, and JMC drafted and revised the manuscript. BJE and JMC supervised this study. SE, GJLaN, ACGMvE, AvdL, DWJD, CBLMM, and YBWEMR critically revised the draft manuscript. BJE and JB are responsible as guarantor for this study. All authors participated in patient enrolment and data acquisition, critically reviewed the manuscript, and approved the final version.

    • Funding The MR CLEAN Registry was funded and carried out by the Erasmus University Medical Centre, Amsterdam University Medical Centers, location AMC, and Maastricht University Medical Centre. The study was additionally funded by the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie[TWIN]).

    • Competing interests CBLMM and YBWEMR received funds from the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie - TWIN) Foundation (related to this project, paid to institution). CBLMM received funds from CVON/Dutch Heart Foundation, Stryker, European Commission, Health Evaluation Netherlands (unrelated; all paid to institution). DWJD and AvdL received research grants from Dutch Heart Foundation, Brain Foundation Netherlands, the Netherlands Organisation for Health Research and Development and Health Holland Top Sector Life Sciences and Health, and unrestricted grants from AngioCare BV, Medtronic/Covidien/EV3, Medac Gmbh/Lamepro, Penumbra Inc, Stryker, Top Medical/Concentric, Thrombolytic Science LLC, Stryker European Operations BV and Cerenovus. YBWEMR and CBLMM are shareholders of Nico.laboratory. CBLMM, YBWEMR, and JMC were principal investigators of the MR CLEAN NO IV trial. DWJD and AvdL were principal investigators of the MR CLEAN MED trial. JMC reports grants from Medtronic, Boehringer Ingelheim, and Bayer outside the submitted work.

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

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