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Updated: Mar 25, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With
Olvert A Berkhemer1, Ivo G H Jansen1, Debbie Beumer1
1From the Departments of Radiology (O.A.B., I.G.H.J., M.E.S.S., R.v.d.B., L.F.M.B., A.M.M.B., C.B.L.M.M.), Neurology (L.A.v.d.B., Y.B.W.E.M.R.), and Biomedical Engineering and Physics (A.M.M.B., H.A.M.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Neurology (O.A.B., P.S.S.F., D.W.J.D.), Radiology (P.S.S.F., A.v.d.L.), and Public Health (H.F.L.), Erasmus MC University Medical Center Rotterdam, The Netherlands; Departments of Neurology (D.B., R.J.v.O.), and Radiology (W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, The Netherlands; Texas Stroke Institute, TX (A.J.Y.); Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands (S.F.M.J.); Department of Radiology, MC Haaglanden, The Hague, The Netherlands (G.J.L.à.N.); Department of Radiology, Leiden University Medical Center, The Netherlands (M.A.A.v.W.); Department of Radiology, VU Medical Center, Amsterdam, The Netherlands (J.C.J.B.); and Department of Robotics & Mechatronics, University of Twente, Enschede, The Netherlands (A.M.M.B., C.H.S.).
Insights
Intra-arterial treatment (IAT) for acute ischemic stroke shows greatest benefit in patients with good collateral circulation. Patients with poor or absent collaterals may not benefit from IAT.
Area of Science:
- Neurology
- Interventional Radiology
- Stroke Medicine
Background:
- Intra-arterial treatment (IAT) using retrievable stents is a proven benefit for acute ischemic stroke.
- Collateral status may influence IAT efficacy, with poorer collaterals potentially reducing clinical benefit.
Purpose of the Study:
- To assess if collateral status on baseline computed tomographic angiography modifies the treatment effect of IAT.
- Post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN).
Main Methods:
- Utilized multivariable ordinal logistic regression with interaction terms.
- Collateral status was graded from 0 (absent) to 3 (good) on baseline computed tomographic angiography.
- Analyzed treatment effect modification by collateral status in the MR CLEAN trial.
Main Results:
- Significant modification of treatment effect by collaterals was observed (P=0.038).
- The greatest benefit of IAT was in patients with good collaterals (grade 3, aOR 3.2).
- Benefit decreased with moderate (aOR 1.6), poor (aOR 1.2), and absent collaterals (aOR 1.0).
Conclusions:
- Baseline collateral status significantly modifies the treatment effect of IAT in acute ischemic stroke.
- IAT provides the most benefit for patients with good baseline collaterals.
- Patients with absent or poor collaterals may experience limited or no benefit from IAT.
Background And Purpose:
Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN).
Methods:
MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status.
Results:
We found a significant modification of treatment effect by collaterals (P=0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7-6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0-2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7-2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1-8.7] for patients with absent collaterals (grade 0).
Conclusions:
In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals.
Clinical Trial Registration:
URL: http://www.trialregister.nl and http://www.controlled-trials.com. Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.
