Association between type of intervention center and outcomes after endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry

Abstract

Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) is performed in intervention centers that provide the full range of neuro(endo)vascular care (level 1) and centers that only perform EVT for AIS (level 2). We compared outcomes between these center types and assessed whether differences in outcomes could be explained by center volume (CV). Patients and methods: We analyzed patients included in the MR CLEAN Registry (2014–2018), a registry of all EVT-treated patients in the Netherlands. Our primary outcome was the shift on the modified Rankin scale (mRS) after 90 days (ordinal regression). Secondary outcomes were the NIHSS 24–48 h post-EVT, door-to-groin time (DTGT), procedure time (linear regression), and recanalization (binary logistic regression). We compared outcomes between level 1 and 2 centers using multilevel regression models, with center as random intercept. We adjusted for relevant baseline factors, and in case of observed differences, we additionally adjusted for CV. Results: Of the 5144 patients 62% were treated in level 1 centers. We observed no significant differences between center types in mRS (adjusted(a)cOR: 0.79, 95% CI: 0.40 to 1.54), NIHSS (aβ: 0.31, 95% CI: −0.52 to 1.14), procedure duration (aβ: 0.88, 95% CI: −5.21 to 6.97), or DTGT (aβ: 4.24, 95% CI: −7.09 to 15.57). The probability for recanalization was higher in level 1 centers compared to level 2 centers (aOR 1.60, 95% CI: 1.10 to 2.33), and this difference probably depended on CV. Conclusions: We found no significant differences, that were independent of CV, in the outcomes of EVT for AIS between level 1 and level 2 intervention centers.

Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials

“…The DAWN and DEFUSE-3 trials demonstrated the efficacy of mechanical thrombectomy in the extended time window up to 24 hours from time last seen well. The MR CLEAN LATE, 8 CLEAR, 34 and RESCUE BT studies 33 showed that selection of patients to EVT in the late window can be performed by evaluation of a good NCCT and/or good collaterals on CTA, particularly in light of the positive results from the large ischemic core trials. The performance of such imaging paradigms is more widely available and accessible compared with advanced imaging techniques.…”

“…The MR CLEAN LATE trial demonstrated better outcomes in patients treated with EVT in mRS ordinal shift analysis. 8 Other trials including RESILIENT Extend (NCT02216643) and NO-CTP (NCT05230914) will also evaluate the use of NCCT for patient selection to EVT in the late window.…”

“…Across multiple randomized clinical trials in the early and late window, recanalization has been proven to improve functional outcomes. 5 6 7 8…”

Evolving Role of Imaging in Acute Ischemic Stroke Care

“…As the community is still adapting to this new evidence, the MR CLEAN LATE trial (Endovascular Treatment of Acute Stroke for Late Arrivals Trial) 4 and recent trials on large ischemic volumes 5 suggest that advanced imaging may lose its central role even for late window or large core patients, emphasizing that with sound clinical judg ment, EVT is rarely harmful in proximal occlusions.…”

Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke

“…However, these recommendations may change based on the results of recently completed and ongoing large core studies. [8][9][10] The routine use of multimodal imaging offers additional advantages in stroke research based on a survey of the workshop participants. For example, at comprehensive stroke centers, the routine use of multimodal imaging is recommended to facilitate endovascular stroke research aimed at refining EVT eligibility criteria (eg, There is no consensus of the optimal imaging protocol for primary and comprehensive stroke centers.…”