Impact of single phase CT angiography collateral status on functional outcome over time: results from the MR CLEAN Registry.

BACKGROUND: Collateral status modified the effect of endovascular treatment (EVT) for stroke in several randomized trials. We assessed the association between collaterals and functional outcome in EVT treated patients and investigated if this association is time dependent. METHODS: We included consecutive patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN) Registry (March 2014-June 2016) with an anterior circulation large vessel occlusion undergoing EVT. Functional outcome was measured on the modified Rankin Scale (mRS) at 90 days. We investigated the association between collaterals and mRS in the MR CLEAN Registry with ordinal logistic regression and if this association was time dependent with an interaction term. Additionally, we determined modification of EVT effect by collaterals compared with MR CLEAN controls, and also investigated if this was time dependent with multiplicative interaction terms. RESULTS: 1412 patients were analyzed. Functional independence (mRS score of 0-2) was achieved in 13% of patients with grade 0 collaterals, in 27% with grade 1, in 46% with grade 2, and in 53% with grade 3. Collaterals were significantly associated with mRS (adjusted common OR 1.5 (95% CI 1.4 to 1.7)) and significantly modified EVT benefit (P=0.04). None of the effects were time dependent. Better collaterals corresponded to lower mortality (P<0.001), but not to lower rates of symptomatic intracranial hemorrhage (P=0.14). CONCLUSION: In routine clinical practice, better collateral status is associated with better functional outcome and greater treatment benefit in EVT treated acute ischemic stroke patients, independent of time to treatment. Within the 6 hour time window, a substantial proportion of patients with absent and poor collaterals can still achieve functional independence.

Yield of Repeat Targeted Direct in-Bore Magnetic Resonance-Guided Prostate Biopsy (MRGB) of the Same Lesions in Men Having a Prior Negative Targeted MRGB.

Objective: This study's purposes were to determine the yield of repeat direct in-bore magnetic resonance-guided prostate biopsy (MRGB) (MRGB-2) after the first one was found to be negative (MRGB-1), to correlate with clinical parameters, and to present the subgroup analyses of patients with positive repeat biopsies, despite having a negative initial biopsies. Materials and Methods: We retrospectively included patients with MRGB-2 after a negative MRGB-1 both between January 2006 and August 2016. This study included 62 patients (median age, 63 years; interquartile range [IQR], 58-66 years) with 75 sampled lesions during MRGB-2 left for analysis, and 63 lesions were resampled and 12 new lesions were sampled. Included patients had a prostate specific antigen (PSA) at MRGB-1 of 13 ng/mL (IQR, 5.8-20.0) and a PSA at MRGB-2 of 15 ng/mL (IQR, 9.0-22.5). All anonymized magnetic resonance imaging (MRI) data were retrospectively reassessed according to Prostate Imaging-Reporting and Data System version 2 by two radiologists. Images of MRGB were compared to determine whether the same prostate lesion was biopsied during MRGB-1 and MRGB-2. Descriptive statistics were utilized to determine the yield of clinically significant prostate cancer (csPCa) at MRGB-2. Gleason score of ≥ 3 + 4 was considered csPCa. Results: In 16/75 (21%) lesions csPCa was detected during MRGB-2. Of 63 resampled lesions, 13 (21%) harbored csPCa at MRGB-2. In two patients, csPCa was detected on repeat biopsy, while the volume of the lesion decreased between MRGB-1 and MRGB-2. Conclusion: Patients could benefit from repeat biopsy after negative initial MRGB, especially in the case of increasing PSA values and persisting PCa suspicion in MRI. Further research is needed to establish predictors for positive repeat targeted biopsies.

Does prior antiplatelet treatment improve functional outcome after intra-arterial treatment for acute ischemic stroke?

Background and purpose In patients with acute ischemic stroke who receive antiplatelet treatment, uncertainty exists about the effect and safety of intra-arterial treatment. Our aim was to study whether intra-arterial treatment in patients with prior antiplatelet treatment is safe and whether prior antiplatelet treatment modifies treatment effect. Methods All 500 MR CLEAN patients were included. We estimated the effect of intra-arterial treatment with ordinal logistic regression analysis, and tested for interaction of antiplatelet treatment with intra-arterial treatment on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results The 144 patients (29%) on antiplatelet treatment were older, more often male, and had more vascular comorbidity. Intra-arterial treatment effect size after adjustments in antiplatelet treatment patients was 1.7 (95% confidence interval 0.9-3.2), and in no antiplatelet treatment patients 1.8 (95% confidence interval: 1.2-2.6). There was no statistically or clinically significant interaction between prior antiplatelet treatment and the relative effect of intra-arterial treatment ( p = 0.78). However, in patients on antiplatelet treatment, the effect of successful reperfusion on functional outcome in the intervention arm of the trial was doubled: the absolute risk difference for favorable outcome after successful reperfusion in patients on prior antiplatelet treatment was 39% versus 18% in patients not on prior antiplatelet treatment (Pinteraction = 0.025). Patients on antiplatelet treatment more frequently had a symptomatic intracranial hemorrhage (15%) compared to patients without antiplatelet treatment (4%), without differences between the control and intervention arm. Conclusions Prior treatment with antiplatelet agents did not modify the effect of intra-arterial treatment in patients with acute ischemic stroke presenting with an intracranial large vessel occlusion. There were no safety concerns. In patients with reperfusion, antiplatelet agents may improve functional outcome.