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Abstract

Background and Purpose—

Nonagenarians represent a growing stroke population characterized by a higher frailty. Although endovascular therapy (ET) is a cornerstone of the management of acute ischemic stroke related to large vessel occlusion, the benefit of reperfusion among nonagenarians is poorly documented. We aimed to assess the impact of ET-related reperfusion on the functional outcome of reperfusion in this elderly population.

Methods—

A retrospective analysis of clinical and imaging data from all patients aged over 90 included in the ETIS (Endovascular Treatment in Ischemic Stroke) registry between October 2013 and April 2018 was performed. Association between post-ET reperfusion and favorable (modified Rankin Scale [0–2] or equal to prestroke value) and good (modified Rankin Scale [0–3] or equal to prestroke value) outcome were evaluated. Demographic and procedural predictors of functional outcome, including the first-pass effect, were evaluated. Results were adjusted for center, admission National Institutes of Health Stroke Scale, and use of intravenous thrombolysis.

Results—

Among the 124 nonagenarians treated with ET, those with successful reperfusion had the lowest 90-day modified Rankin Scale (odds ratio, 3.26; 95% CI, 1.04–10.25). Only patients with successful reperfusion after the first pass (n=53, 56.7%) had a reduced 90-day mortality (odds ratio, 0.15; 95% CI, 0.05–0.45) and an increased rate of good outcome (odds ratio, 4.55; 95% CI, 1.38–15.03). No increase in the rate of intracranial hemorrhage was observed among patients successfully reperfused.

Conclusions—

Successful reperfusion improves the functional outcome of nonagenarians who should not be excluded from ET. The first-pass effect should be considered in the procedural management of this frail population.

Introduction

Although people aged over 90 represent a growing population of patients admitted for ischemic stroke (IS), they are poorly represented in most of the clinical trials because of exclusion criteria, either including age itself or age-associated comorbidities, such as the level of prestroke disability.
However, aging is also associated with an increased rate of atrial fibrillation, which is one of the most frequent sources of intracranial large vessel occlusion (LVO).1 Therefore, there is a growing need to answer the question of the benefit-risk ratio of endovascular therapy in very elderly patients.
According to the meta-analysis of the main clinical trials that evaluate mechanical thrombectomy (MT) over standard care for adults presenting an IS related to an LVO in the anterior circulation, the benefit of MT is stable across different age categories and could even be stronger in patients aged over 80 years.2
However, the sample of patients aged over 80 years was very limited in each study and only represented 15.5% of the total sample in the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patients.3 Therefore, it remains very difficult to ascertain that MT is suitable in nonagenarians.
Indeed, these very elderly patients represent a highly vulnerable population, usually managed by geriatricians, with more frailty, disabilities, and comorbidities, but also more tortuous arteries, than younger patients that could preclude the benefit of MT. Until a recent individual meta-analysis, the benefit-risk ratio of intravenous thrombolysis (IVT) was also questioned due to the poor outcome observed following IS with high rates of intracerebral hemorrhage and early death.4
Similarly, additional data are mandatory to confirm the benefit of MT in nonagenarians and provide new determinants of a favorable outcome. The most powerful predictors of a good outcome across age groups are a lower National Institutes of Health Stroke Scale (NIHSS) at baseline, a shorter delay between onset and reperfusion, and high Alberta Stroke Program Early CT Score on initial brain imaging.5 In addition, recent studies have emphasized the potential role of a first-pass effect (FPE) in MT, defined as achieving complete recanalization with a single thrombectomy device pass, as a strong determinant of favorable outcome.6
The aim of this study was to assess, in the specific population of nonagenarians admitted for an IS related to an LVO, the influence of MT-related reperfusion on the 3-month functional outcome.

Methods

Patients and Data

This observational study retrospectively analyzed clinical and imaging data prospectively gathered from 7 different comprehensive stroke centers (Foch Hospital, Rothschild Foundation, Nantes University Hospital, Bordeaux University Hospital, Nancy University Hospital, Montpellier University Hospital, Lyon University Hospital) participating in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Among the data between 2013 and 2018 of all patients who underwent MT for IS, we included all patients aged over 90 years presenting an IS with LVO of anterior or posterior circulation. Data gathered within the framework of the ETIS registry will be made available for replication or further collaboration on request to Dr Lapergue and after clearance by the local ethics committee in Paris
There were no systematic exclusion criteria on prestroke modified Rankin Scale (mRS), extreme NIHSS (low or high), or infarct core volume at the initial assessment.
Data collection and analyses were approved by local institutional review boards.

Endovascular Treatment

Procedures were performed using third-generation thrombectomy devices (aspiration catheter or stent retriever), and validated modalities were left to the discretion of the operator of each stroke center. Choice of local or general anesthesia depended on medical condition and the need for general anesthesia. At the end of the procedure, the interventional neuroradiologist attributed a modified Thrombolysis in Cerebral Infarction (mTICI) score. A successful reperfusion was defined as mTICI≥2b grade after the endovascular procedure. A magnetic resonance imaging or a computed tomography was systematically performed between 12 and 72 hours in the follow-up, to track a hemorrhagic transformation.

Data Collected

Clinical and radiological conditions were evaluated on admission (NIHSS, Alberta Stroke Program Early CT Score, site of occlusion, technical procedures, prestroke mRS, cardiovascular risk factors, prestroke antithrombotic agent), during hospitalization (association with IVT, mTICI after MT procedure), at discharge (procedural complications, existence of any type of hemorrhage), and after 90 days (mRS, mortality). Timelines of care were also recorded. mRS at 90-day was assessed via a telephone or face-to-face conversation with an experienced nurse dedicated to clinical research by the center.

Outcome Definitions

The prespecified primary outcome of the present study was the favorable outcome defined as a 90-day mRS score of 0 to 2 or equal to the prestroke value. Secondary outcomes were the good outcome defined as mRS score of 0 to 3 or equal to the prestroke value, 90-day all-cause mortality, incidence of intracerebral hemorrhage (ECASS [European Cooperative Acute Stroke Study] classification), and procedural complications (including dissection, embolism in a new territory, and intracranial arterial perforation).

Statistical Analysis

Categorical variables were expressed as frequencies and percentages and continuous variables as means (SD) or medians (interquartile range) for nonnormal distribution. Normality of distributions was assessed graphically and by using the Shapiro-Wilk test.
The overall rates of efficacy and safety outcomes were calculated with their 95% CIs. Patients were divided into 2 groups according to successful reperfusion defined as mTICI≥2b grade at the end of the endovascular procedure. Bivariate comparisons in baseline characteristics and clinical outcomes between the 2 study groups were made using the Student t test (or the Mann-Whitney U test in cases of deviation from normal distribution) for continuous variables or using the χ2 test (or Fisher exact tests when expected cell frequency <5) for categorical variables. Differences in clinical outcomes (favorable outcome, good outcome, 90-day all-cause mortality, any hemorrhage, and procedural complications) between groups were expressed as odds ratios with their 95% CIs. Comparisons in outcomes were further adjusted for prespecified factors (admission NIHSS and IVT) using mixed logistic regression analysis with center as a random effect and other covariates as fixed effects.
When the data were missing, no data imputation was performed.
We further investigated the effect of successful perfusion on clinical efficacy outcomes (favorable outcome, good outcome, 90-day all-cause mortality) by differentiating patients with successful reperfusion after the first device pass (FPE) and those with successful reperfusion requiring >1 device pass. Statistical testing was conducted at the 2-tailed α-level of 0.05. Data were analyzed using the SAS software package, release 9.4 (SAS Institute, Cary, NC).

Results

From October 2013 to April 2018, 124 patients aged over 90 years were consecutively treated by MT in the 7 participating centers (124/1899, 6.5%; Flow-chart, Figure in the online-only Data Supplement). Main patient and treatment characteristics are reported in Table 1.
Table 1. Baseline Characteristics According to Successful Reperfusion
CharacteristicsSuccessful Reperfusion (mTICI 2b/3)P Value
No (n=27)Yes (n=97)
Age, y, mean (SD)92.0 (2.2)92.4 (2.3)0.49
Men10/27 (37)24/97 (24.7)0.21
Medical history
 Hypertension22/27 (81.5)71/91 (78)0.70
 Diabetes mellitus3/27 (11.1)7/89 (7.9)0.70
 Hypercholesterolemia7/27 (25.9)22/90 (24.4)0.88
 Current smoking0/25 (0)2/86 (2.3)NA
 Antithrombotic medication17/26 (65.4)56/88 (63.6)0.87
  Antiplatelet6/26 (23.1)29/87 (33.3)0.32
  Anticoagulant11/26 (42.3)26/87 (29.9)0.24
Current stroke event
 Prestroke mRS score <216/26 (61.5)65/93 (69.9)0.42
 Direct admission16/27 (59.3)34/93 (37.4)0.043
 Site of occlusion
  M1/M2-MCA21/27 (77.8)55/93 (59.1)0.32
  Intracranial ICA4/27 (14.8)20/93 (21.5) 
  Extracranial ICA and Tandem2/27 (7.4)10/93 (10.8) 
  Vertebrobasilar0/27 (0)8/93 (8.6) 
Admission score
 NIHSS, median (IQR)17 (12–19)19 (16–22)0.071
 ASPECTS, median (IQR)7 (5–9)8 (7–9)0.087
Stroke cause
 Atherosclerosis3/23 (13)8/85 (9.4)0.46
 Cardioembolic18/23 (78.3)61/85 (71.8) 
 Others2/23 (8.7)16/85 (18.8) 
Endovascular treatment
 IV r-tPA9/27 (33.3)50/95 (52.6)0.077
 General anesthesia5/27 (18.5)7/93 (7.6)0.14
First-line MT strategy
 SR13/25 (52)29/92 (31.5)0.11
 CA10/25 (40)43/92 (46.7) 
 SR+CA2/25 (8)20/92 (21.7) 
Procedural times, min, median (IQR)
 Onset to imaging129 (99–179)123 (95–161)0.40
 Imaging to puncture127 (77–163)112 (85–147)0.81
 Onset to groin puncture194 (155–306)242 (184–302)0.22
Values expressed as n/total n (%) unless otherwise indicated. ASPECTS indicates Alberta Stroke Program Early CT Score; CA, contact aspiration; ICA, internal carotid artery; IQR, interquartile range; IV r-tPA, intravenous recombinant tissue-type plasminogen activator; MCA, middle cerebral artery; mRS, modified Rankin Scale; MT, mechanical thrombectomy; mTICI, modified Thrombolysis in Cerebral Infarction; NA, not applicable; NIHSS, National Institutes of Health Stroke Scale; and SR, stent retriever.

Successful Reperfusion and Outcomes

At 90 days, 23.5% of patients (n=28, 95% CI, 16.1%–31.9%) had favorable outcome (mRS score, 0–2), 32.8% (n=39, 95% CI, 24.2%–41.6%) had a good outcome (mRS score, 0–3), and 34.4% had died (n=41, 95% CI, 25.8%–43.4%). The main safety and efficacy outcomes are summarized in Table I in the online-only Data Supplement.
As shown in the Figure, patients with successful reperfusion had lower 90-day mRS scores than patients without successful reperfusion (odds ratio of 3.26; 95% CI, 1.04–10.25; P=0.006). This difference was mainly due to a decreased mortality risk in cases of successful reperfusion (28.7% versus 53.8% in patients without successful reperfusion, P=0.017). However, no such difference was observed when only favorable outcome was analyzed. In multivariate analysis adjusted for center, admission NIHSS, and IVT, the difference in 90-day all-cause mortality and good outcomes remained significant (Table 2).
Table 2. Clinical Efficacy and Safety Outcomes According to Successful Reperfusion at the End of Endovascular Procedure
 Successful ReperfusionUnadjustedAdjusted*
No (n=27)Yes (n=97)OR (95% CI)P ValueOR (95% CI)P Value
Efficacy outcomes
 Favorable outcome4/26 (15.4)24/94 (25.5)1.89 (0.59–6.03)0.282.69 (0.74–9.77)0.13
 Good outcome4/26 (15.4)35/94 (37.2)3.26 (1.04–10.25)0.0354.76 (1.35–16.75)0.015
 90-day mortality14/26 (53.8)27/94 (28.7)0.34 (0.14–0.84)0.0170.29 (0.11–0.76)0.012
Safety outcomes
 Any hemorrhage7/24 (29.2)28/67 (36.4)1.39 (0.51–3.75)0.521.22 (0.42–3.53)0.71
 Procedural complications3/27 (11.1)17/97 (18.1)1.77 (0.48–6.55)0.561.31 (0.32–5.45)0.71
Values expressed as n/total n (%) unless otherwise indicated. OR were calculated using patients without successful reperfusion as reference group. Successful reperfusion was defined as mTICI 2b/3 at end of endovascular procedure. Favorable outcome was defined as a 90-day mRS score of 0–2 or equal to the prestroke value. Good outcome was defined as a 90-day mRS score of 0–3 or equal to the prestroke value. IV r-tPA indicates intravenous recombinant tissue-type plasminogen activator; mRS, modified Rankin Scale; mTICI, modified Thrombolysis in Cerebral Infarction; NIHSS, National Institutes of Health Stroke Scale; and OR, odds ratio.
*
Adjusted for center, IV r-tPA, and admission NIHSS.
Figure. Distribution of modified Rankin Scale score at 90 days according to successful reperfusion status. P value from Mann-Whitney U test is reported. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction 2b/3 at the end of endovascular procedure

Patients’ Characteristics According to Successful Recanalization

None of these baseline characteristics differed according to successful reperfusion status except direct admission, which was more frequent in patients without successful reperfusion (59.3% versus 37.4% in patients with successful reperfusion, P=0.043; Table 1).

First-Pass Effect

In the group of patients who have achieved successful reperfusion, only those with successful reperfusion after the first pass (n=53, 56.7%) were associated with a decrease in 90-day mortality (odds ratio, 0.15; 95% CI, 0.05–0.45) and an increase in good outcome (odds ratio, 4.55; 95% CI, 1.37–15.03) compared with patients without reperfusion (Table 3). Similar results were found after adjustment on center, admission NIHSS, and IVT.
Table 3. Clinical Efficacy and Safety Outcomes According to Successful Reperfusion After First Pass Effect
OutcomesSuccessful ReperfusionUnadjustedAdjusted*
 n/Total n (%)OR (95% CI)P ValueOR (95% CI)P Value
Favorable outcomeNo4/26 (15.4)1.00 (ref)1.00 (ref)
1 device pass16/53 (30.2)2.38 (0.70–8.03)0.163.63 (0.93–14.17)0.064
>1 device pass7/38 (18.4)1.24 (0.32–4.76)0.752.07 (0.45–9.52)0.34
Good outcomeNo4/26 (15.4)1.00 (ref)1.00 (ref)
1 device pass24/53 (45.3)4.55 (1.38–15.03)0.0137.06 (1.87–26.63)0.004
>1 device pass10/38 (26.3)1.96 (0.54–7.11)0.303.29 (0.78–13.86)0.10
90-day mortalityNo14/26 (53.8)1.00 (ref)1.00 (ref)
1 device pass8/53 (15.1)0.15 (0.05–0.45)<0.0010.16 (0.04–0.42)<0.001
>1 device pass18/38 (47.4)0.77 (0.28–2.10)0.610.60 (0.20–1.77)0.35
OR were calculated using patients without successful reperfusion as reference group. Successful reperfusion was defined as mTICI 2b/3. Favorable outcome was defined as a 90-day mRS score of 0–2 or equal to the prestroke value. Good outcome was defined as a 90-day mRS score of 0–3 or equal to the prestroke value. IV r-tPA indicates intravenous recombinant tissue-type plasminogen activator; mRS, modified Rankin Scale; mTICI, modified Thrombolysis in Cerebral Infarction; NIHSS, National Institutes of Health Stroke Scale; and OR, odds ratio.
*
Adjusted for center, IV r-tPA, and admission NIHSS.

Safety

Procedural complications occurred in 16.5% (n=20; 95% CI, 10.4%–24.4%) of patients; there were 6 embolic events in a new territory, 1 embolism in the same territory, 5 vessel perforations, 2 vasospasms, 2 dissections, and 4 other complications: 3 groin hematomas and 1 subarachnoid hemorrhage. Intracranial hemorrhage within 24 hours occurred in 28.2% (n=35, 95% CI, 25.5%–44.8%), and only 4 (4%) were considered as symptomatic. According to the ECASS classification, there were 15 cases of hemorrhagic infarction type I, 9 hemorrhagic infarction type II, 4 parenchymal hematoma type I, and 4 parenchymal hematoma type II. Four subarachnoid hemorrhages were observed. Regarding safety outcomes, there was no difference in any intracranial hemorrhage or procedural complication rates between patients with and without successful reperfusion (Table 2).

Discussion

The main results of this large cohort study of nonagenarians treated by endovascular therapy for an IS related to an LVO are that (1) successful reperfusion is a major determinant of good outcome and lower mortality in this frail population and (2) the FPE strongly contributes to the benefit of this reperfusion.
Interestingly, the positive effect of MT on functional outcome observed in this study is consistent with the results reported in the elderly population of the main clinical trials summarized in the HERMES meta-analysis.2 However, the limited sample size of 198 patients aged over 80 years in this meta-analysis was the main drawback to obtaining a firm conclusion. Of note, with a sample size of 124 patients aged over 90 years, our present study is one of the largest in the field, therefore, reinforcing the strong statistical trend of the benefit of reperfusion strategies previously reported in the very elderly. Despite these results, recent studies have reported contradictory results on this topic; Alawieh et al7 failed to demonstrate, in a population of patients aged over 80 years selected on perfusion CT imaging, any significant improvement in rates of good outcome, although a higher incidence of hemorrhage was observed. The shorter delay between onset and groin puncture (239 versus 414 minutes), the use of new generation devices such as aspiration (45% versus 0%) and the higher rate of first-pass recanalization (45% versus 37%) could explain this difference, emphasizing the need to optimize all the parameters of acute management in this vulnerable population.
Nonagenarians represent a frail population due to their high incidence of prestroke medical comorbidities and reduced poststroke neuroplasticity and has a well-known increased susceptibility in to develop poststroke complications (ie, delirium, swallowing disorder, infections). These parameters might explain why only few patients reach a favorable outcome following successful reperfusion.
Together with prestroke mRS, NIHSS severity at baseline and stroke volume are strong predictors of stroke outcome. However, additional parameters are requested to improve patient’s selection. The good outcome of the oldest patients in the ESCAPE trial (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) where patients with large infarct cores or poor collateral circulation, and the most recent results from the HERMES collaboration group about perfusion imaging support the need to use advanced brain imaging in old patients.8
In this population, the association of MT and IVT is also a matter of debate. Although a benefit of IVT in elderly patients with IS has been repeatedly reported,9 some authors have highlighted an increased rate of intracranial hemorrhage.4 Here, we observed that there was a trend to achieve more frequently a successful reperfusion in patients receiving IVT (P=0.07). This result reinforces the current recommendation to combine IVT and MT,10 even in very elderly patients.
Besides the recanalization rate, the characteristics of the MT procedure appears to influence the efficiency of reperfusion. Similarly to Zaidat et al,6 who reported that the FPE was an independent predictor of good clinical outcome and low mortality rate, our results suggest that this procedural parameter is a significantly critical determinant of good clinical outcome at 90 days in the oldest patients. FPE can be partly explained by a reduced delay between onset and cerebral reperfusion and related freezing of the extension of the infarct core volume.11 By reducing the procedural length, the FPE may also contribute to limit the incidence of procedural complications that are more frequent in the elderly.12 This result regarding the FPE raises the question of whether one should interrupt the procedure after the first pass in nonagenarians if this procedure fails.
The results of the present study should be interpreted cautiously due to several limitations. First, the ETIS registry was completed for patients who were addressed to MT, and not all patients presented with LVO. Our population of nonagenarians had a high NIHSS score and a high ASPECTS with short onset to groin puncture delay which may indicate a selection bias and testify to an awareness of the need of selection in this fragile population. Secondly, the cognitive outcome was not evaluated, whereas the cognitive dimension is also important in elderly patients. Third, our results could have been underestimated because of the development of a new generation of MT devices during our period of recruitment. Our results highlight the need to optimize the revascularization strategy in very elderly patients to increase the rate of FPE; for this purpose, the use of combination devices (aspiration and stent retriever) could be the object of future investigation.

Conclusions

In nonagenarians with LVO IS, despite a known poorer outcome compared with younger patients, MT improved the rate of good outcome and reduced mortality at 90 days when successful reperfusion was achieved after the first pass of the device. After identification of nonagenarians who will be expected to benefit from MT, we should employ all means at our disposal to achieve a successful reperfusion after the first pass. In cases of first-pass failure, termination of procedure might be advisable in this fragile population.

Acknowledgments

We thank Mary Osborne-Pellegrin for help in editing the final draft of the article.

Supplemental Material

File (str_stroke-2019-026448d_supp1.pdf)

Appendix

On behalf of the ETIS—Research Investigators

Michel Piotin, Raphaël Blanc, Hocine Redjem, Simon Escalard, Jean-Philippe Desilles, Hocine Redjem, Gabriele Ciccio, Stanislas Smajda, Mikaël Mazighi, Robert Fahed, Mikael Obadia, Candice Sabben, Ovide Corabianu, Thomas de Broucker, Didier Smadja, Sonia Alamowitch, Olivier Ille, Eric Manchon, Pierre-Yves Garcia, Guillaume Taylor, Malek Ben Maacha.
Adrien Wang, Serge Evrard, Maya Tchikviladze, Vadim Afanasiev, Nadia Ajili, Bénédicte Sensenbrenner, Bertrand Lapergue, Oguzhan Coskun, Arturo Consoli, Federico Di Maria, Georges Rodesch, Bruno Del Sette, Riccardo Russo, Katsuhiro Mizutani, Morgan Leguen, Julie Gratieux, Fernando Pico, Haja Rakotoharinandrasana, Philippe Tassan, Roxanna Poll.
Norbert Nighoghossian, Roberto Riva, Omer Eker, Francis Turjman, Laurent Derex, Tae-Hee Cho, Laura Mechtouff, Anne Claire Lukaszewicz, Frédéric Philippeau, Serkan Cakmak, Karine Blanc-Lasserre, Anne-Evelyne Vallet.
Gaultier Marnat, Florent Gariel, Xavier Barreau, Jérôme Berge, Louis Veunac, Patrice Menegon, Igor Sibon, Ludovic Lucas, Stéphane Olindo, Pauline Renou, Sharmila Sagnier, Mathilde Poli, Sabrina Debruxelles.
Romain Bourcier, Lili Detraz, Benjamin Daumas-Duport, Pierre-Louis Alexandre, Monica Roy, Cédric Lenoble, Vincent L’allinec, Jean-Baptiste Girot, Hubert Desal, Solène de Gaalon, Benoit Guillon.
Benjamin Gory, Serge Bracard, René Anxionnat, Marc Braun, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, François Zhu, Emmanuelle Schmitt, Sophie Planel, Sébastien Richard, Lisa Humbertjean, Gioia Mione, Jean-Christophe Lacour, Mathieu Bonnerot, Nolwenn Riou-Comte, Isabelle Costa, Anne Chatelain.
Vincent Costalat, Caroline Arquizan, Cyril Dargazanli, Grégory Gascou, Pierre-Henri Lefèvre, Imad Derraz, Carlos Riquelme, Nicolas Gaillard, Isabelle Mourand et Lucas Corti, Eugene Francois, Stéphane Vannier.

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History

Received: 19 April 2019
Revision received: 15 July 2019
Accepted: 23 July 2019
Published online: 17 September 2019
Published in print: November 2019

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Keywords

  1. aged
  2. first pass effect
  3. frailty
  4. nonagenarians
  5. reperfusion
  6. risk
  7. thrombectomy

Subjects

Authors

Affiliations

Eve Drouard-de Rousiers, MD
From the Department of Neurology, Stroke Center (E.D.-d.R., B.L.), Foch Hospital, Suresnes, France
Ludovic Lucas, MD
Department of Neurology, Stroke Unit, Bordeaux University Hospital, France (L.L.)
Sébastien Richard, MD, PhD
Department of Neurology (S.R.)
Arturo Consoli, MD
Department of Interventional Neuroradiology (A.C), Foch Hospital, Suresnes, France
Mikaël Mazighi, MD, PhD
Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France (M.M., R. Blanc)
Julien Labreuche, BST
University of Lille, University Hospital of Lille, EA2694 -Santé publique: épidémiologie et qualité des soins, France (J.L., M.K.)
Maéva Kyheng, BST
University of Lille, University Hospital of Lille, EA2694 -Santé publique: épidémiologie et qualité des soins, France (J.L., M.K.)
Benjamin Gory, MD, PhD
Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (B.G.)
Cyril Dargazanli, MD, MSc
Department of Interventional Neuroradiology (C.D.), CHRU Gui de Chauliac, Montpellier, France
Caroline Arquizan, MD
Department of Neurology (C.A.), CHRU Gui de Chauliac, Montpellier, France
Gaultier Marnat, MD
Department of Diagnostic and Interventional Neuroradiology (G.M.), University Hospital of Bordeaux, France
Raphaël Blanc, MD, MSc
Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France (M.M., R. Blanc)
Hubert Desal, MD, PhD
Department of Neuroradiology, University Hospital of Nantes, France (H.D., R. Bourcier).
Romain Bourcier, MD, PhD
Department of Neuroradiology, University Hospital of Nantes, France (H.D., R. Bourcier).
Igor Sibon, MD, PhD
Department of Neurology, Stroke Center (I.S.), University Hospital of Bordeaux, France
Bertrand Lapergue, MD, PhD [email protected]
From the Department of Neurology, Stroke Center (E.D.-d.R., B.L.), Foch Hospital, Suresnes, France
On behalf of the ETIS—Research Investigators

Notes

*
A list of all ETIS (Endovascular Treatment in Ischemic Stroke) Investigators Group is given in the Appendix.
Guest Editor for this article was Eric E. Smith, MD, MPH.
The online-only Data Supplement is available with this article at Supplemental Material.
Correspondence to Bertrand Lapergue, MD, PhD, Division of Neurology, Stroke Center, Foch Hospital, University Versailles St-Quentin en Yvelines, Suresnes, France. Email [email protected]

Disclosures

Dr Mazighi has been a consultant and received personal fees from Medtronic, Boehringer and Acticor Biotech. Dr Blanc and Michel Piotin received Institutional grants from Stryker, Medtronic, Microvention, and Balt and are proctors for Medtronic Pipeline Case. Dr Lapergue received grants from Microvention, Penumbra, and Stryker. The other authors report no conflicts.

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