Stroke Laterality Did Not Modify Outcomes in the HERMES

Meta-Analysis of Individual Patient Data of 7 Trials

Mohammed A. Almekhlafi, MD, MSc; Michael D. Hill, MD, MSc; Yvo M. Roos, MD;
Bruce C.V. Campbell, MBBS, PhD; Keith W. Muir, MD; Andrew M. Demchuk, MD;
Serge Bracard, MD; Meritxell Gomis, MD; Francis Guillemin, MD; Tudor G. Jovin, MD;
Bijoy K. Menon, MD, MSc; Peter Mitchell, MD; Philip White, MD; Aad van der Lugt, MD;
Jeffrey Saver, MD; Scott Brown, PhD; Mayank Goyal, MD, PhD

Background and Purpose—There is contradictory evidence on the impact of the stroke side (hemisphere) on outcomes. We
investigated any effect modification by laterality on stroke patients’ outcomes in recent endovascular trials.
Methods—Individual patient-level data were combined in this meta-analysis of all patients included in randomized trials
comparing endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation
ischemic patients with stroke (HERMES [Highly Effective Reperfusion Using Multiple Endovascular Devices]
Collaboration). We stratified the 90-day functional outcome assessed by ordinal analysis of the modified Rankin Scale
according to the stroke side of patients treated with endovascular therapy versus standard care, adjusted for important
prognostic variables.
Results—The meta-analysis included 1737 patients (871 right hemispheric strokes and 866 left hemispheric) from 7 trials.
Baseline median National Institutes of Health Stroke Scale scores were significantly higher in left (20) versus right
(16) hemispheric strokes (P<0.001). Other clinical and radiological baseline characteristics were similar. The beneficial
response to endovascular therapy assessed by 90-day modified Rankin Scale shift was not modified by the side of the
stroke. There were no significant differences between right and left hemispheric stroke in the 90-day functional outcome
(modified Rankin Scale score ≤2; 40.7% [95% CI, 37.4%–44.1%] versus 37.6% [95% CI, 37.4%–44.1%]; P=0.19),
median final infarct volumes (45 versus 39.5 mL, P=0.51), nor 90-day mortality (15.1% vs 16.8%, P=0.31).
Conclusions—Stroke side was not a prognostic factor and did not modify the treatment effect among patients treated in
Downloaded from http://ahajournals.org by on August 5, 2019

the endovascular or control groups in recent endovascular thrombectomy trials.   (Stroke. 2019;50:2118-2124. DOI:
10.1161/STROKEAHA.118.023102.)
Key Words: meta-analysis ◼ patient ◼ risk ◼ stents ◼ thrombolysis

E ndovascular thrombectomy (EVT) is a robust treatment

with proven safety and efficacy in patients with anterior
circulation large vessel occlusions.1,2 Many factors have been
shown to influence the outcome of EVT, for example, the time
from onset to reperfusion,3 whereas other factors have not
been investigated consistently. The importance of the hemi-
spheric side of stroke is uncertain given conflicting evidence
in published studies.4–7
Language deficits characterizing left hemispheric stroke
may be more clinically evident and receive more weight in

Received August 2, 2018; final revision received April 14, 2019; accepted May 13, 2019.
From the Department of Clinical Neurosciences, Radiology, and Community Health Sciences; Hotchkiss Brain Institute, and O’Brien Institute for
Public Health, Cumming School of Medicine, University of Calgary, Foothills Hospital, Alberta, Canada (M.A.A.); Department of Neurology, Faculty of
Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.A.); Department of Clinical Neurosciences, Radiology, and Community Health Sciences;
Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Alberta, Canada (M.D.H.); Academic Medical Center,
Department of Neurology, Amsterdam, the Netherlands (Y.M.R.); Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne
Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.); Institute of Neuroscience and Psychology, University of Glasgow, Scotland, United
Kingdom (K.W.M.); Departments of Clinical Neurosciences and Radiology (A.M.D.), Departments of Clinical Neurosciences and Radiology (B.K.M.),
and Departments of Clinical Neurosciences and Radiology (M. Goyal), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,
Canada; Department of Diagnostic and Interventional Neuroradiology, INSERM U 947 (S. Bracard) and INSERM CIC 1433 Clinical Epidemiology (F.G.),
Université de Lorraine and University Hospital of Nancy, France; Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol,
Badalona, Spain (M. Gomis); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.G.J.); Department of Radiology,
Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.); Institute of Neuroscience, Newcastle University, Newcastle upon Tyne,
United Kingdom (P.W.); Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Stroke Center and
Department of Neurology, University of California, Los Angeles (J.S.); and Altair Biostatistics, St. Louis Park, MN (S. Brown).
Guest Editor for this article was Markku Kaste, MD, PhD.
The online-only Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.118.023102.
Correspondence to Mayank Goyal, MD, PhD, Seaman Family MR Research Centre, University of Calgary, Foothills Medical Centre, 1403–29 St NW,
Calgary, AB T2N 2T9. Email mgoyal@ucalgary.ca
© 2019 American Heart Association, Inc.
Stroke is available at https://www.ahajournals.org/journal/str DOI: 10.1161/STROKEAHA.118.023102

2118
 Almekhlafi et al   Laterality and Stroke Outcome in the HERMES Collaboration   2119

stroke severity scales compared to hemispatial neglect,8 a
hallmark of right hemispheric strokes. Hemispatial neglect
may be associated with delays in presentation and subsequent
management differences between right versus left hemisphere
stroke patients.9 Moreover, because patients with right hemi-
sphere stroke have lower scores on the National Institutes of
Health Stroke Scale (NIHSS) compared with left hemisphere
stroke of equivalent volume,7 patients with seemingly less se-
vere (right sided) stroke may have poorer outcomes.10 Studies
have reported a higher incidence of silent infarcts,11 a higher
risk of poststroke hospital-acquired pneumonia,12 and a higher
risk of hemorrhagic transformation following thrombolysis in
right compared with left hemisphere stroke patients).13 Several
studies have not found a difference in the 90-day functional
outcome or mortality in right versus left hemisphere stroke
patients receiving intravenous alteplase (tPA [tissue-type plas-
minogen activator]).14,15
We assessed whether stroke laterality impacted the out-
come of patients with large vessel occlusions in the anterior
circulation who were enrolled in major endovascular trials.
Methods
Study Design
The authors declare that all supporting data are available within the
article (and its online-only Data Supplement). The HERMES (Highly
Effective Reperfusion Using Multiple Endovascular Devices) collab-
oration is a prospective individual-patient-level meta-analysis done in
accordance with PRISMA guidelines (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) of data from 7 major trials:
the MR CLEAN (Endovascular Treatment for Acute Ischemic Stroke
in the Netherlands),16 ESCAPE (Endovascular Treatment for Small
Core and Proximal Occlusion Ischemic Stroke),17 EXTEND-IA
(Extending the Time for Thrombolysis in Emergency Neurological
Deficits—Intra-Arterial),18 SWIFT PRIME (Solitaire FR as Primary
Treatment for Acute Ischemic Stroke),19 REVASCAT (Endovascular
Revascularization With Solitaire Device Versus Best Medical Therapy

Table 1. Baseline Characteristics of Patients in the EVT and Control Groups According to the Stroke Side

Left Right
EVT Group Control Group Heterogeneity EVT Group Control Group (439 Heterogeneity
Characteristic (424 Patients) (442 Patients) P Value (432 Patients) Patients) P Value
Age, y 65.7±13.4 (424) 65.1±13.6 (442) 0.497 65.4±13.3 (432) 66.3±13.5 (438) 0.315
Female sex 43.2% (183/424) 43.9% (194/442) 0.837 50.7% (219/432) 50.3% (221/439) 0.946
Baseline systolic blood pressure 147.0±24.9 (423) 145.1±24.7 (439) 0.271 143.0±22.1 (431) 145.3±24.1 (438) 0.150
Hypertension 54.2% (230/424) 56.8% (251/442) 0.453 52.4% (225/429) 60.1% (264/439) 0.024
Hyperlipidemia 37.0% (152/411) 38.6% (168/435) 0.670 33.8% (143/423) 41.7% (179/429) 0.020
Downloaded from http://ahajournals.org by on August 5, 2019

Diabetes mellitus 14.7% (62/423) 17.4% (77/442) 0.308 14.9% (64/430) 17.8% (78/438) 0.271
Atrial fibrillation 33.7% (109/323) 28.6% (99/346) 0.156 32.9% (111/337) 37.2% (123/331) 0.257
Prior stroke 10.0% (42/421) 9.3% (41/441) 0.817 12.4% (53/427) 11.0% (48/438) 0.527
Smoking 41.2% (155/376) 36.1% (146/404) 0.162 34.3% (137/400) 37.1% (151/407) 0.419
Blood glucose, mg/dL 136.7±101.5 (410) 128.1±44.6 (425) 0.111 128.2±38.8 (419) 132.1±68.8 (431) 0.319
Median NIHSS at baseline [20.0] (16.0–22.0) [20.0] (15.0–23.0) 0.714 [16.0] (13.0–18.0) [16.0] (12.0–18.0) 0.387
Median ASPECTS at baseline [8.0] (7.0–9.0) [8.0] (7.0–9.0) 0.899 [8.0] (7.0–9.0) [8.0] (7.0–9.0) 0.908
tPA administered 88.7% (376/424) 89.6% (396/442) 0.743 86.1% (372/432) 91.8% (403/439) 0.009
Transfer subject 21.8% (92/422) 29.7% (130/438) 0.008 22.5% (97/432) 20.0% (88/439) 0.385
Occlusion location (central reading) 0.851 0.484
 Missing 6.1% (26/424) 6.8% (30/442) 4.2% (18/432) 5.9% (26/439)
 ICA 25.0% (106/424) 24.2% (107/442) 25.0% (108/432) 27.3% (120/439)
 M1 59.7% (253/424) 60.6% (268/442) 65.0% (281/432) 60.6% (266/439)
 M2 9.0% (38/424) 8.4% (37/442) 5.8% (25/432) 5.9% (26/439)
Collateral grade (central reading) 0.220 0.750
 0 0.0% (0/313) 1.2% (4/334) 1.9% (6/322) 1.3% (4/315)
 1 14.4% (45/313) 16.5% (55/334) 14.3% (46/322) 16.8% (53/315)
 2 46.0% (144/313) 44.3% (148/334) 42.5% (137/322) 40.3% (127/315)
 3 39.6% (124/313) 38.0% (127/334) 41.3% (133/322) 41.6% (131/315)
Median onset to tPA administration [117.0] (85.0–155.0) [113.0] (83.0–155.0) 0.528 [115.0] (85.0–154.3) [120.0] (85.0–165.0) 0.056
Categorical data are presented as % (n/N), and continuous data are presented as mean±SD (N) [median] (IQR). Continuous variables presented between square
brackets are medians. ASPECTS indicates Alberta Stroke Program Early CT Score; EVT, endovascular thrombectomy; ICA, internal carotid artery, IQR, interquartile range;
M1, M1-segment of the middle cerebral artery; M2, M2-segment of the middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; and tPA, tissue-type
plasminogen activator.
 2120  Stroke  August 2019

in Anterior Circulation Stroke Within 8 Hours),20 PISTE (Pragmatic
Ischaemic Thrombectomy Evaluation),21 and THRACE (Trial and
Cost-Effectiveness Evaluation of Intra-Arterial Thrombectomy in
Acute Ischemic Stroke)22 trials. The detailed of the HERMES col-
laboration (The Highly Effective Reperfusion evaluated in Multiple
Endovascular Stroke Trials) initiation and the methodology of the
meta-analysis search strategy and data gathering has been previously
reported.1,23 The investigators searched PubMed database for ran-
domized controlled trials comparing EVT versus standard medical
therapy and published between 2010 and 2017. The current study is a
post hoc analysis of individual patient data from the aforementioned
7 randomized trials.
Stroke Program Early CT Score, the location of the occlusion, treat-
ment with intravenous alteplase (yes or no), and time to randomiza-
tion. In addition, given the known NIHSS differences between right
versus left hemisphere strokes,7 the analyses were repeated without
adjusting for baseline NIHSS differences. To capture any effect of
the stroke side on presentation or treatment delays, we tabulated the
different time metrics and compared them according to the stroke side
in the 2 treatment groups. Safety outcomes included the 90-day mor-
tality, the proportion of patients with symptomatic intracerebral hem-
orrhage (as defined by each trial), and with a parenchymal hematoma
type 2 (cerebral blood clot with mass effect). Statistical analyses, in-
cluding production of figures, were done with SAS, version 9.4.

Baseline Characteristics and Outcomes Results

For the current analysis, baseline clinical (as age, vascular risk fac-
tors, stroke severity) and imaging (including the findings of the com-
puted tomography [CT] head and CT angiography) characteristics
according to stroke side were summarized and tabulated. Laterality
assessment was missing for 31 patients. Outcome variables were
compared between the interventional and control treatment groups
according to the stroke side, and both the primary effect of laterality
in each treatment group and the interaction term testing modification
of treatment effect by laterality were assessed.
Statistical Analysis
Our primary objective was to test whether hemispheric side of large
vessel occlusion stroke influenced the 90-day functional outcome in
HERMES trial. The probability of each outcome as a function of the
affected side was analyzed using mixed-method ordinal logistic re-
gression for ordinal outcomes (modified Rankin Scale [mRS]) and
mixed-method binary logistic regression for binary 90-day outcomes
(mRS 0–1, mRS 0–2, mortality) with trial and trial-by-treatment in-
teraction as random-effects variables. Missing data were not imputed,
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A total of 1737 patients (871 right hemisphere strokes, 866
left hemisphere strokes) were analyzed. There was no differ-
ence in the mean age or baseline vascular risk factors between
the 2 groups. Baseline NIHSS was significantly higher in the
left hemisphere stroke versus right hemisphere stroke (me-
dian 20 versus 16, respectively, P<0.001). Baseline Alberta
Stroke Program Early CT Score (median 8) was similar in the 2
groups, as was the mean systolic blood pressure. Occlusion site
and collateral grades were comparable (Table 1). Intravenous
alteplase was administered to 89% of patients in both groups
(P=0.9). Important time metrics as the onset to alteplase ad-
ministration and onset to arterial puncture did not differ signifi-
cantly (Table 1). There was no difference in the median onset to
alteplase administration times between the EVT versus control
groups in the right and left hemisphere stroke patients.
Outcome data were available for 1718 patients. In the
endovascular arm, there was no difference in the proportion

and available data were used for modeling and analysis results.
Between-trial heterogeneity was examined, and no significant dif-
ferences between trials in the laterality effect on key end points nor
were there meaningful differences when employing a fixed-effects
model to handle trial effect. The proportional odds assumption was
assessed by comparison of binary odds ratios across each possible
dichotomization (eg, 0 versus 1–6, 0–1 versus 2–6, etc). No evi-
dence of substantial nonproportionality was found across the various
dichotomizations.
The analyses were adjusted for important baseline clinical and
imaging variables; these were age, sex, NIHSS at baseline, Alberta
of patients with an independent 90-day functional outcome,
defined as an mRS score 0 to 2 among those with right hem-
isphere stroke (49.5%) versus left hemisphere stroke (46.4%,
P=0.37). The proportion of patients with excellent 90-day
functional outcome (mRS, 0–1) was not different in those
with right hemisphere stroke (30.5%) versus left hemisphere
stroke (28.2%, P=0.46). Similarly, the outcomes in the control
arm were similar in the right hemisphere stroke and left hem-
isphere stroke patients (Table 2).

Table 2. Outcomes in the EVT and Control Groups Classified by Laterality (Outcome Data Were Available for 1718 Patients)

Left Right
EVT Group Control Group EVT Group Control Group
Characteristic (424 Patients) (442 Patients) P Value (432 Patients) (439 Patients) P Value
Median mRS at 90 days [3.0] (1.0–4.0) [4.0] (2.0–5.0) <0.001 [3.0] (1.0–4.0) [4.0] (2.0–5.0) <0.001
mRS 0–1 28.2% (119/422) 14.9% (65/436) <0.001 30.5% (131/430) 18.4% (79/430) <0.001
mRS 0–2 46.4% (196/422) 29.1% (127/436) <0.001 49.5% (213/430) 31.9% (137/430) <0.001
90-day mortality 16.3% (69/424) 17.4% (76/437) 0.716 13.2% (57/431) 17.0% (74/435) 0.130
Median NIHSS at 24 h [10.0] (4.0–19.0) [17.0] (9.0–22.0) <0.001 [8.0] (3.0–15.0) [12.0] (6.0–17.0) <0.001
Change in NIHSS at 24 h −6.7±8.6 (403) −3.4±7.2 (417) <0.001 −5.8±7.9 (417) −2.9±6.1 (427) <0.001
Parenchymal hematoma type 2 5.7% (24/419) 4.4% (19/433) 0.434 5.4% (23/426) 5.3% (23/431) 1.000
Symptomatic ICH 2.9% (12/416) 3.4% (15/436) 0.699 4.7% (20/424) 3.7% (16/430) 0.500
Final infarct volume [30.3] (11.4–99.0) [48.6] (18.7–132.7) 0.051 [36.1] (11.3–103.2) [52.4] (17.3–134.0) 0.064
Categorical data are presented as % (n/N), and continuous data are presented as mean±SD (N) [median] (IQR). Continuous variables presented between
square brackets are medians. EVT indicates endovascular thrombectomy; ICH, intracranial hemorrhage; IQR, interquartile range; mRS, modified Rankin Scale;
and NIHSS, National Institutes of Health Stroke Scale.
 Almekhlafi et al   Laterality and Stroke Outcome in the HERMES Collaboration   2121

Treatment with endovascular therapy produced signifi-
cant beneficial effect in patients with left (adjusted common
odds ratio, 1.92; 95% CI, 1.51–2.45; P<0.001) and right hem-
ispheric strokes (2.34; 95% CI, 1.51–3.62; P<0.001; Table I
in the online-only Data Supplement). This was seen across
the distribution of the mRS when stratified by the side or by
treatment allocation and side (Figure 1 and Figure I in the
online-only Data Supplement).24 Omitting baseline NIHSS as
covariate did not impact these results (Table II in the online-
only Data Supplement). There was no evidence of treatment
effect modification by laterality (interaction P value for hetero-
geneity=0.667, for ordinal mRS, There was also no difference
in the proportion of patients with mRS 0 to 2 and 0 to 1 groups
(Figure 2) or other end points analyzed. Lower follow-up
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infarct volume with EVT was observed in both right and left
hemisphere stroke. When right and left hemisphere stroke
patients are combined irrespective of the treatment allocation,
the median (interquartile range) follow-up infarct volume were
45 (107) for right side and 39.5 (106) for left side, respectively
(P=0.51). The median 24-hour NIHSS was lower in the right
hemisphere stroke compared with left hemisphere stroke (10
versus 14, P<0.001) combined irrespective of the treatment al-
location. The rates of 90-day mortality or symptomatic intra-
cranial hemorrhage did not differ between stroke sides.
Discussion
In this meta-analysis, which included patients from multiple
centers in different countries and healthcare systems, the side

Figure 1. Distribution of modified Rankin Scale (mRS; available for 1718 patients) according to (A) the treatment group stratified by the side and (B) accord-
ing to the stroke side stratified by treatment group assignment. The thin red lines denote P values for each level of the mRS were >0.1.24 EVT indicates endo-
vascular thrombectomy.
 2122  Stroke  August 2019
Figure 2. Forest plot of endovascular thrombectomy (EVT) treatment
effect (Adj ORs) by laterality in various subgroups. Adj OR indicates
adjusted odds ratio; FIV, final infarct volume; mRS, modified Rankin Scale;
PH2, parenchymal hematoma type 2; and sICH, symptomatic intracranial
hemorrhage.
of affected hemisphere did not impact the speed or response
to endovascular therapy. Baseline stroke severity measured by
Downloaded from http://ahajournals.org by on August 5, 2019
the NIHSS was higher in left hemisphere stroke patients, con-
sistent with previous studies and with the weighting of the scale
components towards language function. Because the extent of
early ischemic changes on CT and pattern of occlusion sites
did not differ by lateralization, this is likely a function of scale
properties rather than a true difference in severity. We did ob-
serve a delay in the time from onset to alteplase administration
in patients with right hemisphere stroke in the control group.
However, baseline differences did not impact the patients’ out-
comes as right hemisphere stroke and left hemisphere stroke
patients in the control arms had similar 90-day functional out-
come and mortality rates. The baseline and 24-hour NIHSS
were lower in right hemisphere stroke patients which is likely
attributed to the more substantial weight assigned to language
in the NIHSS scoring,7 although the magnitude of the drop in
NIHSS from baseline to 24 hours was not different.
Evidence regarding the effect of stroke side on outcome is
contradictory. Some retrospective and prospective cohort stud-
ies described better clinical outcome in left hemisphere stroke
patients.4,25 This association was attributed to the longer onset
to presentation time,5,9 and larger infarct volume in patients
with right versus left hemisphere stroke.26 Worse outcomes and
higher mortality with right hemisphere stroke versus left hem-
isphere stroke were reported even with similar baseline stroke
severity and infarct volumes.4 Lower proportions of right hemi-
sphere stroke patients received intravenous tPA as some of them
were not immediately recognized as strokes.9 Lower rehabilita-
tion potential due to neglect or emotional indifference in right
hemisphere stroke has also been suggested.4,6 Other investigators
challenged these reports and described no difference in outcomes
between right and left hemisphere stroke after adjustment for in-
farct volume assessed using magnetic resonance imaging.14
The NIHSS score gives more weight to language (a left
hemispheric function in most of the population which receives
at least 7 out of the 42 maximum points: level of consciousness
questions and commands, and language) than hemispatial and
visual neglect (3 points). Our analysis illustrates that as left
hemisphere stroke patients had a 4-point higher baseline and
24-hour NIHSS scores compared with right hemisphere stroke
patients. This lack of equanimity in scoring the NIHSS for
right and left hemisphere strokes could negatively impact some
important therapeutic decisions that rely on NIHSS thresholds
for thrombolytic administration, transfer to a higher care cen-
ters, or referral for decompressive hemicraniectomy.7,27 The
hemisphere affected by stroke may need to be specified and
considered in conjunction with NIHSS. Our analysis showing
no difference in follow-up infarct volume or outcomes between
right hemisphere stroke versus left hemisphere stroke despite
the significant difference in baseline and 24-hour NIHSS rein-
forces the inherent hemispheric bias of the NIHSS.
The contradictory evidence in the literature and the find-
ings of our analysis may be reconciled by the following con-
siderations. The robust prospective randomized design of the
studies included in our analysis remove many of the biases
associated with observational studies and controls for many
confounders. Therefore, clinical and imaging baseline imbal-
ances and potential confounding could explain the findings
of some of the prior studies that reported outcome difference
according to laterality. The acute medical management and
follow-up of patients in the included trials suggest that post-
treatment factors may not have been well controlled in prior
studies. However, these acute therapeutic measures do not
necessarily reflect the routine practices or outcomes in nonter-
tiary-care centers. Other potential limitations of our analysis
include the unknown denominator of patients with right and
left hemisphere stroke who were screened for trial enrollment.
It is possible that more patients with right hemisphere stroke,
for example, were excluded from enrollment due to poor
Alberta Stroke Program Early CT Score or low NIHSS and
ended up with poorer outcomes compared with their left hem-
isphere stroke counterparts. A single-center study showed that
52% of right hemispheric stroke patients with NIHSS score
of 6 to 12 received EVT compared with 81% of those with
left hemispheric stroke (P=0.03).28 Finally, although mRS is
the standard measure of 90-day functional outcome, patients
could still be disabled by neglect or dysphasia yet score well
on the available functional assessment scores.
Conclusions
In this meta-analysis of 7 randomized controlled trials, the
side of affected hemisphere did not modify the outcome in
any of the treatment groups nor did it diminish the benefits
patients attained from EVT.
Sources of Funding
The University of Calgary received an unrestricted grant from
Medtronic for the HERMES (Highly Effective Reperfusion Using
Multiple Endovascular Devices) collaboration initiative. The com-
pany had no role in the: design of the studies, data collection, data
 Almekhlafi et al   Laterality and Stroke Outcome in the HERMES Collaboration   2123
analysis or interpretation, drafting the reports, or the decision to
submit the reports for publication. The corresponding author had full
access to all the data in the study and had final responsibility for the
decision to submit for publication.
Disclosures
Dr Hill owns stock in Calgary Scientific Incorporated, a company that
focuses on medical imaging software, is a director of the Canadian
Federation of Neurological Sciences, a not-for-profit group and
has received research grant support from Alberta Innovates Health
Solutions, Canadian Institutes of Health Research, Heart & Stroke
Foundation of Canada, Medtronic National Institutes of Neurological
Disorders and Stroke. He consulted for Boehringer Ingelheim. Dr
Roos reports other from Stock owner of Nico-Lab, outside the sub-
mitted work. Dr Campbell reports grants from National Health and
Medical Research Council, grants from Royal Australasian College
of Physicians, grants from Royal Melbourne Hospital Foundation,
from National Heart Foundation, from National Stroke Foundation
of Australia, grants from Covidien (Medtronic), during the con-
duct of the study. Dr Muir reports grants from National Institute
of Health Research, Stroke Association, Medtronic, Codman, out-
side the submitted work. He received research support and con-
sulted for Boehringer Ingelheim. Dr Demchuk reports personal
fees from Medtronic, during the conduct of the study. Dr Jovin has
consulted for Codman Neurovascular and Neuravi; holds stock in
Silk Road, Anaconda, Route 92, FreeOx Biotech, and Blockade; re-
ceived travel expenses from Stryker as primary investigator of the
DAWN trial (DWI or CTP Assessment With Clinical Mismatch in
the Triage of Wake Up and Late Presenting Strokes Undergoing
Neurointervention With Trevo) and from Fundacio Ictus related
to the REVASCAT (Randomized Trial of Revascularization with
Solitaire FR Device vs Best Medical Therapy in the Treatment of
Acute Stroke Due to Anterior Circulation Large Vessel Occlusion
Presenting within 8 h of Symptom Onset) and RACECAT (Direct
Downloaded from http://ahajournals.org by on August 5, 2019
Transfer to an Endovascular Center Compared to Transfer to the
Closest Stroke Centre in Acute Stroke Patients With Suspected Large
Vessel Occlusion) trials, and honoraria from Cerenovus. Dr Mitchell
reports other from Medtronic, other from Stryker, personal fees from
Stryker, other from Microvention, outside the submitted work. Dr
White reports grants from National Institutes for Health Research,
the Stroke Association, Medtronic (Covidien), and Codman and has
consulted for Microvention/ Terumo, Stryker, and Codman. He acted
as a member of the global advisory Board on hemorrhagic stroke.
Dr van der Lugt reports grants from Dutch Heart Foundation, other
from AngioCare BV, other from Covidien/EV3, other from MEDAC
Gmbh/LAMEPRO, other from Stryker, other from Penumbra, Inc,
during the conduct of the study; grants from Stryker, grants from
Penumbra Inc, grants from Medtronic, outside the submitted work.
Dr Saver has acted as a scientific consultant regarding trial design
and conduct for Medtronic. He also consulted for Stryker, Neuravi/
Cerenovus, and Rapid Medical. The University of California has pat-
ent rights in retrieval devices for stroke. Dr Brown reports personal
fees from University of Calgary, during the conduct of the study;
personal fees from Medtronic, outside the submitted work. Dr Goyal
reports grants from Medtronic, personal fees from Stryker, personal
fees from Medtronic, personal fees from Microvention, personal
fees from Cerenovus, during the conduct of the study; grants from
Stryker, outside the submitted work. In addition, Dr Goyal has a pat-
ent Systems of Acute Stroke Diagnosis issued to GE Healthcare. The
other authors report no conflicts.
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