@article{discovery10047835,
          number = {4},
            year = {2018},
         journal = {JAMA Neurology},
          volume = {75},
           pages = {453--461},
           title = {Association of reperfusion with brain edema in patients with acute ischemic stroke: A secondary analysis of the MR CLEAN Trial},
           month = {April},
          author = {Kimberly, WT and Dutra, BG and Boers, AMM and Alves, HCBR and Berkhemer, OA and Van Den Berg, L and Sheth, KN and Roos, YBWEM and Van Der Lugt, A and Beenen, LFM and Dippel, DWJ and Van Zwam, WH and Van Oostenbrugge, RJ and Lingsma, HF and Marquering, H and Majoie, CBLM and Koudstaal, PJ and Van Den Berg, LA and Nederkoorn, PJ and Beumer, D and Staals, J and Boiten, J and Wermer, MJH and Kappelle, LJ and Van Dijk, EJ and Schonewille, WJ and Hofmeijer, J and Van Oostayen, JA and Vroomen, PC and De Kort, PLM and Keizer, K and De Bruijn, SF and Van Den Berg, JSP and Schreuder, THCML and Aerden, LAM and Flach, HZ and Visser, MC and Den Hertog, HM and Brouwer, PA and Emmer, BJ and Sprengers, MES and Van Den Berg, R and Nijeholt, GJL and Van Walderveen, MAA and Lo, RH and De Vries, J and Vos, JA and Eshghi, O and Tielbeek, AV and Van Dijk, LC and Van Hasselt, BAAM and Heijboer, RJJ and Dallinga, RJ and Bot, JCJ and Gerrits, DG and Fransen, PSS and Marquering, HA and Steyerberg, EW and Yoo, AJ and Jenniskens, SFM and Van Den Berg-Vos, RM and Karas, GB and Brown, MM and Liebig, T and Stijnen, T and Andersson, T and Mattle, H and Wahlgren, N and Van Der Heijden, E and Ghannouti, N and Fleitour, N and Hooijenga, I and Puppels, C and Pellikaan, W and Geerling, A and Lindl-Velema, A and Van Vemde, G and Klinieken, I and De Ridder, A and Greebe, P and De Bont-Stikkelbroeck, J and De Meris, J and Janssen, K and Struijk, W and Licher, S and Boodt, N and Ros, A and Venema, E and Slokkers, I and Ganpat, RJ},
        abstract = {IMPORTANCE: 
It is uncertain whether therapeutic reperfusion with endovascular treatment yields more or less brain edema. OBJECTIVE To elucidate the association between reperfusion and brain edema. The secondary objectives were to evaluate whether brain edema could partially be responsible for worse outcomes in patients with later reperfusion or lower Alberta Stroke Program Early Computed Tomography Score. 

DESIGN, SETTING, AND PARTICIPANTS: 
This was a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), which was a prospective, randomized, multicenter clinical trial of endovascular treatment compared with conventional care of patients with acute anterior circulation ischemic stroke. Of 502 patients enrolled from December 2010 to June 2014, 2 patients declined to participate. Additionally, exclusion criteria were absence of follow-up imaging or presence of parenchymal hematoma, resulting in 462 patients included in this study. Brain edema was assessed retrospectively, from December 10, 2016, to July 24, 2017, by measuring midline shift (MLS) in all available follow-up scans. Observers were blinded to clinical data. 

MAIN OUTCOMES AND MEASURES: 
Midline shift was assessed as present or absent and as a continuous variable. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction score in the endovascular treatment arm. The modified arterial occlusive lesion score was used to evaluate the recanalization status in both arms. The modified Rankin scale score at 90 days was used for functional outcome. RESULTS Of 462 patients, the mean (SD) age was65 (11) years, and 41.8\% (n = 193) were women. Successful reperfusion and recanalization were associated with a reduced likelihood of having MLS (adjusted common odds ratio, 0.25; 95\% CI, 0.12-0.53; P {\ensuremath{<}} .001 and adjusted common odds ratio, 0.34; 95\% CI, 0.21-0.55; P {\ensuremath{<}} .001, respectively). Midline shift was partially responsible for worse modified Rankin scale scores in patients without reperfusion or recanalization (MLS changed the logistic regression coefficients by 30.3\% and 12.6\%, respectively). In patients with delayed reperfusion or lower Alberta Stroke Program Early Computed Tomography Score, MLS mediated part of the worse modified Rankin scale scores, corresponding to a change in the regression coefficient of 33.3\% and 64.2\%, respectively. 

CONCLUSIONS AND RELEVANCE: 
Successful reperfusion was associated with reduced MLS. This study identifies an additional benefit of reperfusion in relation to edema, as well as rescuing ischemic brain tissue at risk for infarction.},
             url = {http://dx.doi.org/10.1001/jamaneurol.2017.5162},
            issn = {2168-6149}
}