• Olvert A Berkhemer, Jordi Borst, Manon Kappelhof, Albert J Yoo, Lucie A van den Berg, FransenPuck S SPSSFrom Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Netherlands, Debbie Beumer, Wouter J Schonewille, Paul J Nederkoorn, WermerMarieke J HMJHFrom Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Netherlan, Henk A Marquering, Hester F Lingsma, RoosYvo B W E MYBWEMFrom Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Netherlan, Robert J van Oostenbrugge, DippelDiederik W JDWJFrom Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Netherla, Wim H van Zwam, MajoieCharles B L MCBLMFrom Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Nether, Bart J Emmer, Aad van der Lugt, and MR CLEAN Investigators.
• From Academic Medical Center, Amsterdam; Erasmus MC University Medical Center, Rotterdam; Maastricht University Medical Center, Maastricht; Sint Antonius Hospital, Nieuwegein; and Leiden University Medical Center, Leiden, the Netherlands, and Texas Stroke Institute, Plano, Texas.
• Ann. Intern. Med. 2017 Jun 20; 166 (12): 867-875.

BackgroundThe presence of extracranial carotid disease (ECD) is associated with less favorable clinical outcomes in patients with acute ischemic stroke caused by intracranial proximal occlusion. Acute intra-arterial treatment (IAT) in the setting of extracranial and intracranial lesions is considered challenging, and whether it yields improved outcomes remains uncertain.ObjectiveTo examine whether the presence of ECD modified the effect of IAT for intracranial proximal anterior circulation occlusion.DesignPrespecified subgroup analysis of a randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands. (Trial registrations: NTR1804 [Netherlands Trial Register] and ISRCTN10888758).Setting16 hospitals in the Netherlands.PatientsAcute ischemic stroke caused by proximal intracranial arterial occlusion of the anterior circulation. Extracranial carotid disease was defined as cervical internal carotid artery stenosis (>50%) or occlusion.InterventionIAT treatment versus no IAT.MeasurementsThe primary outcome was functional outcome, as measured by the modified Rankin Scale at 90 days and reported as adjusted common odds ratio (acOR) for a shift in direction of a better outcome. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by ECD.ResultsThe overall acOR was 1.67 (95% CI, 1.21 to 2.30) in favor of the intervention. The acOR was 3.1 (CI, 1.7 to 5.8) in the prespecified subgroup of patients with ECD versus 1.3 (CI, 0.9 to 1.9) in patients presenting without ECD. Both acORs are in favor of the intervention (P for interaction = 0.07).LimitationThe study was not powered for subgroup analysis.ConclusionIntra-arterial treatment may be at least as effective in patients with ECD as in those without ECD, and it should not be withheld in these complex patients with acute ischemic stroke.Primary Funding SourceDutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Stryker, and Top Medical/Concentric.

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