Refining endovascular treatment for acute ischemic stroke

This thesis aimed to investigate the additional benefit of iv alteplase (IVT) in patients with a large vessel occlusion stroke who were eligible for endovascular treatment (EVT). In a retrospective study, outcomes after direct EVT were worse, however, bias by indication remained the main limitation in interpreting the results. We therefore set up the MR CLEAN-NO IV trial, which did not show superiority, nor non-inferiority of direct EVT over IVT+EVT.
We further aimed to refine technical targets, by re-evaluating what is considered successful reperfusion, showing that interventionists should always aim for 100% reperfusion, although it remains unclear if they should continue after achieving ≥50% reperfusion. The role of iv alteplase in increasing the percentage of successful reperfusion remains unclear.
We also investigated functional outcome for patients with multivessel occlusions who received EVT. Patients with multiple vessel occlusions have worse outcomes than those with single vessel occlusion. The role of iv alteplase might be substantial in treatment of this group of patients, although EVT should not be withheld.
Finally, we found that EVT patients with large-artery atherosclerotic stroke tended to have better collateral status than EVT patients with cardioembolic stroke. Therefore, there might be a role for underlying stroke etiology and its association with collateral status in improving individualized stroke treatment.