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Ischemic stroke
Original research
Sex differences in outcomes after endovascular treatment in posterior circulation stroke: results from the MR CLEAN Registry
  1. Mariam Ali1,
  2. Luuk Dekker1,
  3. Mahsoem Ali2,
  4. Erik W Van Zwet3,
  5. Jeanette Hofmeijer4,5,
  6. Paul J Nederkoorn6,
  7. Charles BLM Majoie7,
  8. Adriaan CGM van Es8,
  9. Maarten Uyttenboogaart9,
  10. Anne van der Meij1,6,
  11. Marianne A A van Walderveen10,
  12. Marieke C Visser6,
  13. Diederik WJ Dippel11,
  14. Wouter J Schonewille12,
  15. Ido R van den Wijngaard1,13,
  16. Nyika D Kruyt1,
  17. Marieke J H Wermer1,9
  18. on behalf of the MR CLEAN Registry Investigators
    1. 1Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
    2. 2Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
    3. 3Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
    4. 4Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
    5. 5Clinical Neurophysiology, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
    6. 6Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
    7. 7Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
    8. 8Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
    9. 9Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
    10. 10Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
    11. 11Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
    12. 12Department of Neurology, St. Antonius Hospital, Nieuwegein, The Netherlands
    13. 13Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
    1. Correspondence to Mariam Ali, Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; m.ali{at}lumc.nl

    Abstract

    Background Women with anterior circulation large vessel occlusion (LVO) have been reported to have worse outcomes after endovascular treatment (EVT) than men. Whether these disparities also exist in LVO of the posterior circulation is yet uncertain. We assessed sex differences in clinical, technical, and safety outcomes of EVT in posterior circulation LVO.

    Methods We used data of patients with posterior circulation LVO included in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014–2018). Primary outcome was the modified Rankin Scale (mRS) score at 90 days assessed with multivariable ordinal regression analysis. Secondary outcomes included favorable functional outcome (mRS ≤3), functional independence (mRS ≤2), death within 90 days, National Institutes of Health Stroke Scale (NIHSS) score 24–48 hours postintervention, complications, successful reperfusion (extended Thrombolysis in Cerebral Ischemia 2B-3), and procedure duration analyzed with multivariable logistic and linear regression analyses.

    Results We included 264 patients (42% women). Compared with men, women were older (median age 68 vs 63 years), more often had prestroke disability (mRS ≥1: 37% vs 30%), and received intravenous thrombolytics less often (45% vs 56%). Clinical outcomes were similar between sexes (adjusted (common) OR (aOR) 0.82, 95% CI 0.51 to 1.34; favorable functional outcome 50% vs 43%, aOR 1.31, 95% CI 0.77 to 2.25; death 32% vs 29%, aOR 0.98, 95% CI 0.52 to 1.84). In addition, NIHSS score after 24–48 hours (median 7 vs 9), successful reperfusion (77% vs 73%), and complications did not differ between men and women.

    Conclusions Outcomes in women treated with EVT for posterior circulation LVO were similar compared with men despite less favorable baseline characteristics in women. Therefore men and women may benefit equally from EVT.

    • Intervention
    • Stroke
    • Thrombectomy

    Data availability statement

    Data cannot be made available to other researchers, as no patient approval has been obtained for sharing coded data. However, syntax and output files of statistical analyses are available on reasonable request.

    https://doi.org/10.1136/jnis-2023-021086

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      Data availability statement

      Data cannot be made available to other researchers, as no patient approval has been obtained for sharing coded data. However, syntax and output files of statistical analyses are available on reasonable request.

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      Footnotes

      • Twitter @Strokologist, @MariekeWermer

      • Collaborators MR CLEAN Registry Investigators – group authors: 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, location University of Amsterdam); Yvo B.W.E.M. Roos (Neurology, Amsterdam UMC, location University of Amsterdam); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); Jelis Boiten (Neurology, Haaglanden MC, the Hague); Jan Albert Vos (Radiology, Sint Antonius Hospital, Nieuwegein). Study coordinators: Ivo G.H. Jansen (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of 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, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); Kars C.J. Compagne (Radiology, Erasmus MC University Medical Center,)Manon Kappelhof (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Josje Brouwer (Neurology, Amsterdam UMC, location University of 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); Adriaan C.G.M. van Es, Radiology, Erasmus MC University Medical Center, Charles B.L.M. Majoie (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Yvo B.W.E.M. Roos (Neurology, Amsterdam UMC, location University of Amsterdam); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Jonathan M. Coutinho (Neurology, Amsterdam UMC, location University of 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); Julie Staals (Department of Neurology, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); 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(Department Radiology, Elisabeth-TweeSteden ziekenhuis, Tilburg Puck Fransen (Department of Neurology, Elisabeth-TweeSteden ziekenhuis, Tilburg); Jan S.P. van den Berg (Department of Neurology, Isala Kliniek, en, 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) Tomas Bulut(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, location University of Amsterdam); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); 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, location University of Amsterdam); Sjoerd F.M. Jenniskens (Radiology, Radboud University Medical Center, Nijmegen); René van den Berg (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of 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, location University of Amsterdam); Alida A. Postma (Radiology & Nuclear Medicine, Maastricht, the Netherlands), (MHeNs School for Mental Health and Neuroscience, Maastricht, the Netherlands); Stefan D. Roosendaal (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of 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, Erasmus MC University Medical Center); Bart J. Emmer (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of 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 (Radiology, Erasmus MC University Medical Center); 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); Writing 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, location University of Amsterdam); Yvo B.W.E.M. Roos (Neurology, Amsterdam UMC, location University of Amsterdam); Robert J. van Oostenbrugge (Department of Neurology, Maastricht University Medical Center+, School for Cardiovascular Diseases Maastricht (CARIM)Maastricht, the Netherlands); Wim H. van Zwam (Radiology & Nuclear Medicine, Maastricht, the Netherlands), (Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); 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, the Netherlands), (Maastricht University Medical Center+; School for Cardiovascular Diseases Maastricht (CARIM), Maastricht, the Netherlands); Jeannette Hofmeijer (Department of Neurolog, 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, location University of 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, the Netherlands); 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) ; Laurine van der Steen (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam).PhD / Medical students: Esmee Venema (Public Health, Erasmus MC University Medical Center); Vicky Chalos (Department of Neurology, Erasmus MC University Medical Center), (Public Health, Erasmus MC University Medical Center); Ralph R. Geuskens (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of 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, location University of Amsterdam), (Radiology & Nuclear Medicine, Maastricht, the Netherlands); Anna M.M. Boers (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam), (Biomedical Engineering & Physics, Amsterdam UMC, location University of Amsterdam); J. Huguet (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); P.F.C. Groot (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Marieke A. Mens (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Katinka R. van Kranendonk (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Kilian M. Treurniet (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Manon L. Tolhuisen (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam), (Biomedical Engineering & Physics39, Amsterdam UMC, location University of Amsterdam); Heitor Alves (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Annick J. Weterings (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Eleonora L.F. Kirkels (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Eva J.H.F. Voogd (Department of Neurology, Rijnstate Hospital, Arnhem); Lieve M. Schupp (Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam); Sabine L. Collette (Department of Neurology, University Medical Center Groningen), (Radiology, University Medical Center Groningen); root (Neurology, Amsterdam UMC, location University of Amsterdam); Natalie E. LeCouffe (Neurology, Amsterdam UMC, location University of Amsterdam); Praneeta R. Konduri (Biomedical Engineering & Physics, Amsterdam UMC, location University of Amsterdam); Haryadi Prasetya (Biomedical Engineering & Physics, Amsterdam UMC, location University of Amsterdam); Nerea Arrarte-Terreros (Biomedical Engineering & Physics, Amsterdam UMC, location University of Amsterdam); Lucas A. Ramos (Biomedical Engineering & Physics, Amsterdam UMC, location University of Amsterdam)

        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, Ivo G.H. Jansen, Maxim J.H.L. Mulder, Robert- Jan B. Goldhoorn, Kars C.J. Compagne, Manon Kappelhof, Josje Brouwer, Sanne J. den Hartog, Wouter H. Hinsenveld, Lotte van den Heuvel, Bob Roozenbeek, Pieter Jan van Doormaal, Bart J. Emmer, Jonathan M. Coutinho, Wouter J. Schonewille, Marieke J.H. Wermer, Marianne A.A. van Walderveen, Adriaan C.G.M. van Es, Julie Staals, Jeannette Hofmeijer, Jasper M. Martens, Geert J. Lycklama à Nijeholt, 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 L.M. de Kort, Julia van Tuijl, Issam Boukrab, Jo P. Peluso, Puck Fransen, Jan S.P. van den Berg, Heleen M. den Hertog; Heleen M. den Hertog; Boudewijn A.A.M. van Hasselt; Leo A.M. Aerden; René J. Dallinga; Maarten Uyttenboogaart; Omid Eschgi; Reinoud P.H. Bokkers; Tobien H.C.M.L. Schreuder; Roel J.J. Heijboer; Koos Keizer; Rob A.R. Gons; Lonneke S.F. Yo; Emiel J.C. Sturm, Tomas Bulut; Paul J.A.M. Brouwers; Anouk D. Rozeman; Otto Elgersma, Michel J.M. Remmers; Thijs E.A.M. de Jong; Charles B.L.M. Majoie; Wim H. van Zwam; Aad van der Lugt; Marianne A.A. van Walderveen; Marieke E.S. Sprengers; Sjoerd F.M. Jenniskens; René van den Berg; Albert J. Yoo; Ludo F.M. Beenen; Alida A. Postma; Stefan D. Roosendaal; Bas F.W. van der Kallen; Ido R. van den Wijngaard; Adriaan C.G.M. van Es; Bart J. Emmer,; Jasper M. Martens; Lonneke S.F. Yo; Jan Albert Vos; Joost Bot; Pieter-Jan van Doormaal; Anton Meijer; Elyas Ghariq; Reinoud P.H. Bokkers; Marc P. van Proosdij; G. Menno Krietemeijer; Jo P. Peluso; Hieronymus D. Boogaarts; Rob Lo;Wouter Dinkelaar; Auke P.A. Appelman; Bas Hammer; Sjoert Pegge; Anouk van der Hoorn; Saman Vinke; Sandra Cornelissen; Christiaan van der Leij; Rutger Brans; Jeanette Bakker; Maarten Uyttenboogaart; Miou Koopman; Lucas Smagge; Olvert A. Berkhemer; Jeroen Markenstein; Eef Hendriks; Patrick Brouwer; Dick Gerrits.

      • Contributors MA and MJHW: conception and design of the study. MA and MJHW: drafting of the manuscript. MA, LD and MahA: data and statistical analysis. EWvZ: supervision of statistical analysis. LD, AvdM, JH, WJS, MU, MAAvW, IRvdW, ACGMvE, NDK, PJN, MCV: acquisition of clinical data. CBLMM, DWJD: members of the trial executive committee. All authors: critical review and revision of the manuscript for valuable intellectual content. MA is guarantor of the data.

      • Funding The Multicentre Randomised Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in The Netherlands (MR CLEAN) Registry was partly funded by the TWIN Foundation, Erasmus MC University Medical Centre, Amsterdam University Medical Centre, and Maastricht University Medical Centre.

      • Competing interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MJHW reports funding from NWO/ZonMw (VIDI 91717337 and Aspasia). JH reports funding from the Dutch Heart Foundation (CEI 2018T070). CBLMM reports funding from the TWIN Foundation, CVON/Dutch Heart Foundation, European Commission, Healthcare Evaluation Netherlands, and Stryker, all outside the submitted work (paid to institution). In addition, he is shareholder of Nicolab. IRvdW reports consulting fees from Philips, Medtronic, and Neurophyxia. DWJD reports funding from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization 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, all paid to the institution. The other authors had no conflicting interests.

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

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