Randomized Controlled Trial

. 2022 Jun;53(6):1863-1872.

doi: 10.1161/STROKEAHA.121.034919. Epub 2022 Feb 9.

Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry

Kars C J Compagne^#^{1

2}, Manon Kappelhof^#³, Wouter H Hinsenveld⁴, Josje Brouwer⁵, Robert-Jan B Goldhoorn⁴, Maarten Uyttenboogaart⁶, Reinoud P H Bokkers⁷, Wouter J Schonewille⁸, Jasper M Martens⁹, Jeannette Hofmeijer¹⁰, H Bart van der Worp¹¹, Rob T H Lo¹², Koos Keizer¹³, Lonneke S F Yo¹⁴, Geert J Lycklama À Nijeholt¹⁵, Heleen M den Hertog¹⁶, Emiel J C Sturm¹⁷, Paul J A M Brouwers¹⁸, Marianne A A van Walderveen¹⁹, Marieke J H Wermer²⁰, Sebastiaan F de Bruijn²¹, Lukas C van Dijk²², Hieronymus D Boogaarts²³, Ewout J van Dijk²⁴, Julia H van Tuijl, Jo P P Peluso²⁵, Paul L M de Kort²⁶, Boudewijn A A M van Hasselt²⁷, Puck S Fransen¹⁶, Tobien H C M L Schreuder²⁸, Roel J J Heijboer²⁹, Sjoerd F M Jenniskens³⁰, Marieke E S Sprengers³, Elias Ghariq¹⁵, Ido R van den Wijngaard³¹, Stefan D Roosendaal³, Anton F J A Meijer³⁰, Ludo F M Beenen³, Alida A Postma³², René van den Berg³, Albert J Yoo, Pieter Jan van Doormaal¹, Marc P van Proosdij³³, Menno G M Krietemeijer¹⁴, Dick G Gerrits¹⁷, Sebastiaan Hammer, Jan Albert Vos³⁴, Jelis Boiten³¹, Jonathan M Coutinho⁵, Bart J Emmer³, Ad C G M van Es¹⁹, Bob Roozenbeek², Yvo B W E M Roos⁵, Wim H van Zwam³², Robert J van Oostenbrugge⁴, Charles B L M Majoie³, Diederik W J Dippel², Aad van der Lugt; MR CLEAN Registry Investigators

Collaborators, Affiliations

Collaborators

MR CLEAN Registry Investigators:
Ivo G H Jansen, Maxim J H L Mulder, Josje Brouwer, Sanne J den Hartog, Wouter J Schonewille, Jan Albert Vos, Marieke J H Wermer, Marianne A A van Walderveen, Julie Staals, Robert J van Oostenbrugge, 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, Jo P Peluso, Puck Fransen, Jan S P van den Berg, Boudewijn A A M van Hasselt, Leo A M Aerden, René J Dallinga, Omid Eschgi, Tobien H C M L Schreuder, Roel J J Heijboer, Koos Keizer, Lonneke S F Yo, Heleen M den Hertog, Tomas Bulut, Paul J A M Brouwers, Geert J Lycklama À Nijeholt, 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, Jasper M Martens, Lonneke S F Yo, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Reinoud P H Bokkers, Jo P Peluso, Hieronymus D Boogaarts, Rob Lo, Wouter Dinkelaar, Auke P A Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, Charles B L M Majoie, Geert J Lycklama À Nijeholt, Jan Albert Vos, Wouter J Schonewille, Jeannette Hofmeijer, Jasper M Martens, H Bart van der Worp, Rob H Lo, Jeannette Hofmeijer, H Zwenneke Flach, Hester F Lingsma, Naziha El Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, 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, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R Geuskens, Tim van Straaten, Saliha Ergezen, Roger R M Harmsma, Daan Muijres, Anouk de Jong, Olvert A Berkhemer, Anna M M Boers, J Huguet, P F C Groot, Marieke A Mens, Katinka R van Kranendonk, Kilian M Treurniet, Manon L Tolhuisen, Heitor Alves, Annick J Weterings, Eleonora L F Kirkels, Eva J H F Voogd, Lieve M Schupp, Sabine L Collette, Adrien E D Groot, Natalie E LeCouffe, Praneeta R Konduri, Haryadi Prasetya, Nerea Arrarte-Terreros, Lucas A Ramos

Affiliations

¹ Department of Radiology and Nuclear Medicine (K.C.J.C., P.J.v.D.), Erasmus MC, University Medical Center' Rotterdam' the Netherlands.
² Department of Neurology (K.C.J.C., B.R., D.W.J.D.), Erasmus MC, University Medical Center' Rotterdam' the Netherlands.
³ Department of Radiology and Nuclear Medicine (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam' the Netherlands.
⁴ Department of Neurology (W.H.H., R.-J.B.G., R.J.v.O.), School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands.
⁵ Department of Neurology (J.B., J.M.C., Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam' the Netherlands.
⁶ Department of Neurology (M.U.), University Medical Center Groningen' the Netherlands.
⁷ Department of Radiology (R.P.H.B.), University Medical Center Groningen' the Netherlands.
⁸ Department of Neurology (W.J.S.)' Sint Antonius Hospital' the Netherlands.
⁹ Department of Radiology (J.M.M.), Rijnstate Hospital' Arnhem' the Netherlands.
¹⁰ Department of Neurology (J.H.), Rijnstate Hospital' Arnhem' the Netherlands.
¹¹ Department of Neurology and Neurosurgery, Brain Center (H.B.v.d.W.), University Medical Center Utrecht' the Netherlands.
¹² Department of Radiology (R.T.H.L.O.), University Medical Center Utrecht' the Netherlands.
¹³ Department of Neurology (K.K.), Catharina Hospital' Eindhoven' the Netherlands.
¹⁴ Department of Radiology (L.S.F.Y., M.G.M.K.), Catharina Hospital' Eindhoven' the Netherlands.
¹⁵ Department of Radiology (G.J.L.à.N., E.G.), Haaglanden Medical Center' the Netherlands.
¹⁶ Department of Neurology (H.M.d.H., P.S.F.), Isala Klinieken' the Netherlands.
¹⁷ Department of Radiology (E.J.C.S., D.G.G.), Medical Spectrum Twente' the Netherlands.
¹⁸ Department of Neurology (P.J.A.M.B.), Medical Spectrum Twente' the Netherlands.
¹⁹ Department of Radiology (M.A.A.v.W., A.C.G.M.v.E.), Leiden University Medical Center' the Netherlands.
²⁰ Department of Neurology (M.J.H.W.), Leiden University Medical Center' the Netherlands.
²¹ Department of Neurology (S.F.d.B.), HAGA Hospital' the Netherlands.
²² Department of Radiology (L.C.v.D.), HAGA Hospital' the Netherlands.
²³ Department of Neurosurgery (H.D.B.), Radboud University Medical Center' the Netherlands.
²⁴ Department of Neurology (E.J.v.D.), Radboud University Medical Center' the Netherlands.
²⁵ Department of Radiology (J.P.P.), Sint Elisabeth Hospital' the Netherlands.
²⁶ Department of Neurology (P.L.M.d.K.), Sint Elisabeth Hospital' the Netherlands.
²⁷ Department of Radiology (B.A.A.M.v.H.), Isala Klinieken' the Netherlands.
²⁸ Department of Neurology (T.H.C.M.L.), Zuyderland' the Netherlands.
²⁹ Department of Radiology (R.J.J.H.), Zuyderland' the Netherlands.
³⁰ Department of Radiology (S.F.M.J., A.F.J.A.M.), Radboud University Medical Center' the Netherlands.
³¹ Department of Neurology (I.R.v.d.W., J.B.), Haaglanden Medical Center' the Netherlands.
³² Department of Radiology and Nuclear Medicine (A.A.P., W.H.v.Z.), School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands.
³³ Department of Radiology, Noordwest Ziekenhuisgroep' the Netherlands (M.P.v.P.).
³⁴ Department of Radiology (J.A.V.)' Sint Antonius Hospital' the Netherlands.

^# Contributed equally.

PMID: 35135323
PMCID: PMC9126265
DOI: 10.1161/STROKEAHA.121.034919

Randomized Controlled Trial

Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry

Kars C J Compagne et al. Stroke. 2022 Jun.

. 2022 Jun;53(6):1863-1872.

doi: 10.1161/STROKEAHA.121.034919. Epub 2022 Feb 9.

Authors

Collaborators

MR CLEAN Registry Investigators:
Ivo G H Jansen, Maxim J H L Mulder, Josje Brouwer, Sanne J den Hartog, Wouter J Schonewille, Jan Albert Vos, Marieke J H Wermer, Marianne A A van Walderveen, Julie Staals, Robert J van Oostenbrugge, 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, Jo P Peluso, Puck Fransen, Jan S P van den Berg, Boudewijn A A M van Hasselt, Leo A M Aerden, René J Dallinga, Omid Eschgi, Tobien H C M L Schreuder, Roel J J Heijboer, Koos Keizer, Lonneke S F Yo, Heleen M den Hertog, Tomas Bulut, Paul J A M Brouwers, Geert J Lycklama À Nijeholt, 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, Jasper M Martens, Lonneke S F Yo, Joost Bot, Pieter-Jan van Doormaal, Anton Meijer, Elyas Ghariq, Reinoud P H Bokkers, Jo P Peluso, Hieronymus D Boogaarts, Rob Lo, Wouter Dinkelaar, Auke P A Appelman, Bas Hammer, Sjoert Pegge, Anouk van der Hoorn, Saman Vinke, Charles B L M Majoie, Geert J Lycklama À Nijeholt, Jan Albert Vos, Wouter J Schonewille, Jeannette Hofmeijer, Jasper M Martens, H Bart van der Worp, Rob H Lo, Jeannette Hofmeijer, H Zwenneke Flach, Hester F Lingsma, Naziha El Ghannouti, Martin Sterrenberg, Wilma Pellikaan, Rita Sprengers, Marjan Elfrink, Michelle Simons, Marjolein Vossers, Joke de Meris, Tamara Vermeulen, Annet Geerlings, Gina van Vemde, Tiny Simons, 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, Jocova Vervoort, Eva Ponjee, Sharon Romviel, Karin Kanselaar, Denn Barning, Esmee Venema, Vicky Chalos, Ralph R Geuskens, Tim van Straaten, Saliha Ergezen, Roger R M Harmsma, Daan Muijres, Anouk de Jong, Olvert A Berkhemer, Anna M M Boers, J Huguet, P F C Groot, Marieke A Mens, Katinka R van Kranendonk, Kilian M Treurniet, Manon L Tolhuisen, Heitor Alves, Annick J Weterings, Eleonora L F Kirkels, Eva J H F Voogd, Lieve M Schupp, Sabine L Collette, Adrien E D Groot, Natalie E LeCouffe, Praneeta R Konduri, Haryadi Prasetya, Nerea Arrarte-Terreros, Lucas A Ramos

Affiliations

¹ Department of Radiology and Nuclear Medicine (K.C.J.C., P.J.v.D.), Erasmus MC, University Medical Center' Rotterdam' the Netherlands.
² Department of Neurology (K.C.J.C., B.R., D.W.J.D.), Erasmus MC, University Medical Center' Rotterdam' the Netherlands.
³ Department of Radiology and Nuclear Medicine (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam' the Netherlands.
⁴ Department of Neurology (W.H.H., R.-J.B.G., R.J.v.O.), School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands.
⁵ Department of Neurology (J.B., J.M.C., Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam' the Netherlands.
⁶ Department of Neurology (M.U.), University Medical Center Groningen' the Netherlands.
⁷ Department of Radiology (R.P.H.B.), University Medical Center Groningen' the Netherlands.
⁸ Department of Neurology (W.J.S.)' Sint Antonius Hospital' the Netherlands.
⁹ Department of Radiology (J.M.M.), Rijnstate Hospital' Arnhem' the Netherlands.
¹⁰ Department of Neurology (J.H.), Rijnstate Hospital' Arnhem' the Netherlands.
¹¹ Department of Neurology and Neurosurgery, Brain Center (H.B.v.d.W.), University Medical Center Utrecht' the Netherlands.
¹² Department of Radiology (R.T.H.L.O.), University Medical Center Utrecht' the Netherlands.
¹³ Department of Neurology (K.K.), Catharina Hospital' Eindhoven' the Netherlands.
¹⁴ Department of Radiology (L.S.F.Y., M.G.M.K.), Catharina Hospital' Eindhoven' the Netherlands.
¹⁵ Department of Radiology (G.J.L.à.N., E.G.), Haaglanden Medical Center' the Netherlands.
¹⁶ Department of Neurology (H.M.d.H., P.S.F.), Isala Klinieken' the Netherlands.
¹⁷ Department of Radiology (E.J.C.S., D.G.G.), Medical Spectrum Twente' the Netherlands.
¹⁸ Department of Neurology (P.J.A.M.B.), Medical Spectrum Twente' the Netherlands.
¹⁹ Department of Radiology (M.A.A.v.W., A.C.G.M.v.E.), Leiden University Medical Center' the Netherlands.
²⁰ Department of Neurology (M.J.H.W.), Leiden University Medical Center' the Netherlands.
²¹ Department of Neurology (S.F.d.B.), HAGA Hospital' the Netherlands.
²² Department of Radiology (L.C.v.D.), HAGA Hospital' the Netherlands.
²³ Department of Neurosurgery (H.D.B.), Radboud University Medical Center' the Netherlands.
²⁴ Department of Neurology (E.J.v.D.), Radboud University Medical Center' the Netherlands.
²⁵ Department of Radiology (J.P.P.), Sint Elisabeth Hospital' the Netherlands.
²⁶ Department of Neurology (P.L.M.d.K.), Sint Elisabeth Hospital' the Netherlands.
²⁷ Department of Radiology (B.A.A.M.v.H.), Isala Klinieken' the Netherlands.
²⁸ Department of Neurology (T.H.C.M.L.), Zuyderland' the Netherlands.
²⁹ Department of Radiology (R.J.J.H.), Zuyderland' the Netherlands.
³⁰ Department of Radiology (S.F.M.J., A.F.J.A.M.), Radboud University Medical Center' the Netherlands.
³¹ Department of Neurology (I.R.v.d.W., J.B.), Haaglanden Medical Center' the Netherlands.
³² Department of Radiology and Nuclear Medicine (A.A.P., W.H.v.Z.), School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands.
³³ Department of Radiology, Noordwest Ziekenhuisgroep' the Netherlands (M.P.v.P.).
³⁴ Department of Radiology (J.A.V.)' Sint Antonius Hospital' the Netherlands.

^# Contributed equally.

PMID: 35135323
PMCID: PMC9126265
DOI: 10.1161/STROKEAHA.121.034919

Abstract

Background: We evaluated data from all patients in the Netherlands who underwent endovascular treatment for acute ischemic stroke in the past 3.5 years, to identify nationwide trends in time to treatment and procedural success, and assess their effect on clinical outcomes.

Methods: We included patients with proximal occlusions of the anterior circulation from the second and first cohorts of the MR CLEAN (Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry (March 2014 to June 2016; June 2016 to November 2017, respectively). We compared workflow times and rates of successful reperfusion (defined as an extended Thrombolysis in Cerebral Infarction score of 2B-3) between cohorts and chronological quartiles (all included patients stratified in chronological quartiles of intervention dates to create equally sized groups over the study period). Multivariable ordinal logistic regression was used to assess differences in the primary outcome (ordinal modified Rankin Scale at 90 days).

Results: Baseline characteristics were similar between cohorts (second cohort n=1692, first cohort n=1488) except for higher age, poorer collaterals, and less signs of early ischemia on computed tomography in the second cohort. Time from stroke onset to groin puncture and reperfusion were shorter in the second cohort (median 185 versus 210 minutes; P<0.001 and 236 versus 270 minutes; P<0.001, respectively). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 66%; P<0.001). Functional outcome significantly improved (adjusted common odds ratio 1.23 [95% CI, 1.07-1.40]). This effect was attenuated by adjustment for time from onset to reperfusion (adjusted common odds ratio, 1.12 [95% CI, 0.98-1.28]) and successful reperfusion (adjusted common odds ratio, 1.13 [95% CI, 0.99-1.30]). Outcomes were consistent in the analysis per chronological quartile.

Conclusions: Clinical outcomes after endovascular treatment for acute ischemic stroke in routine clinical practice have improved over the past years, likely resulting from improved workflow times and higher successful reperfusion rates.

Keywords: groin odds; puncture; ratio; registry; reperfusion.

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Figures

**Figure 1.**
**Flowchart of included patients.** First cohort: March 2014 to June 2016; second cohort: June 2016 to November 2017. EVT indicates endovascular thrombectomy; and MR CLEAN, Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands.

**Figure 2.**
**Modified Rankin Scale (mRS) scores at 90 d. A**, First cohort (March 2014 to June 2016, n=1488) vs second cohort of the MR CLEAN Registry (June 2016 to November 2017, n=1692). Shift toward better functional outcomes in cohort 2 (age and sex adjusted common odds ratio [acOR], 1.26 [95% CI, 1.11–1.43]). B, Outcomes per chronological quartile of treated patients over time (Q1 n=795, Q2 n=797, Q3 n=793, Q4 n=795; age and sex adjusted acOR, 1.13 [95% CI, 1.06–1.19]). Q indicates quartile.

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Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry

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Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry

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