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Updated: Aug 3, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial
Sven PR Luijten1, Kars CJ Compagne1, Adriaan CGM van Es2
1Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
Background:
Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion.
Methods:
We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation.
Results:
We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74] in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile).
Conclusion:
Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.
Insights
Brain atrophy influences recovery after ischemic stroke. Endovascular treatment benefits patients more with greater brain atrophy, suggesting it should not prevent treatment.
Area of Science:
- Neurology
- Stroke Medicine
- Neuroimaging
Background:
- Brain atrophy is a known factor potentially limiting functional recovery post-acute ischemic stroke.
- The impact of brain atrophy on the efficacy of endovascular treatment for large vessel occlusion stroke requires further investigation.
Purpose of the Study:
- To evaluate if brain atrophy modifies the effectiveness of endovascular treatment in acute ischemic stroke patients with large vessel occlusion.
- To determine the relationship between the degree of brain atrophy and functional outcomes following endovascular intervention.
Main Methods:
- Analysis of data from the MR CLEAN trial involving patients with anterior circulation large vessel occlusion.
- Quantification of brain atrophy using baseline non-contrast computed tomography scans to calculate the ratio of total brain volume to intracranial volume.
- Statistical analysis to assess treatment effect modification by brain atrophy, analyzed as a continuous variable and in tertiles.
Main Results:
- Brain atrophy significantly modified the effect of endovascular treatment on functional outcomes (P=0.04).
- Patients with higher degrees of brain atrophy experienced greater improvements in functional outcomes with endovascular treatment compared to those with lower atrophy.
- The adjusted common odds ratio for better functional outcome increased with higher tertiles of brain atrophy.
Conclusions:
- The benefits of endovascular treatment for acute ischemic stroke are more pronounced in patients with greater brain atrophy.
- Advanced brain atrophy should not be a contraindication for withholding endovascular treatment in eligible patients.
- This finding supports the use of endovascular treatment across a spectrum of brain atrophy severity.
