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Moullaali TJ, Wang X, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Chalmers J, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw JM, Anderson CS, Bath PM. Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. J Neurol Neurosurg Psychiatry 2022; 93:6-13. [PMID: 34732465 PMCID: PMC8685661 DOI: 10.1136/jnnp-2021-327195] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). METHODS A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. RESULTS Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth. INTERPRETATION Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. PROSPERO REGISTRATION NUMBER CRD42019141136.
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Affiliation(s)
- Tom J Moullaali
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lisa J Woodhouse
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Leon Edwards
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Salil Gupta
- Department of Neurology, Army Hospital Research and Referral, New Delhi, India
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Potter
- Stroke Research Group, Norfolk and Norwich University Hospital, UK.,Norwich Medical School, University of East Anglia, UK
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | | | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, California, USA
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia .,Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Knipper M, Mazurek B, van Dijk P, Schulze H. Too Blind to See the Elephant? Why Neuroscientists Ought to Be Interested in Tinnitus. J Assoc Res Otolaryngol 2021; 22:609-621. [PMID: 34686939 PMCID: PMC8599745 DOI: 10.1007/s10162-021-00815-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/30/2021] [Indexed: 01/13/2023] Open
Abstract
A curative therapy for tinnitus currently does not exist. One may actually exist but cannot currently be causally linked to tinnitus due to the lack of consistency of concepts about the neural correlate of tinnitus. Depending on predictions, these concepts would require either a suppression or enhancement of brain activity or an increase in inhibition or disinhibition. Although procedures with a potential to silence tinnitus may exist, the lack of rationale for their curative success hampers an optimization of therapeutic protocols. We discuss here six candidate contributors to tinnitus that have been suggested by a variety of scientific experts in the field and that were addressed in a virtual panel discussion at the ARO round table in February 2021. In this discussion, several potential tinnitus contributors were considered: (i) inhibitory circuits, (ii) attention, (iii) stress, (iv) unidentified sub-entities, (v) maladaptive information transmission, and (vi) minor cochlear deafferentation. Finally, (vii) some potential therapeutic approaches were discussed. The results of this discussion is reflected here in view of potential blind spots that may still remain and that have been ignored in most tinnitus literature. We strongly suggest to consider the high impact of connecting the controversial findings to unravel the whole complexity of the tinnitus phenomenon; an essential prerequisite for establishing suitable therapeutic approaches.
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Affiliation(s)
- Marlies Knipper
- Molecular Physiology of Hearing, Tübingen Hearing Research Centre (THRC), Department of Otolaryngology, Head & Neck Surgery, University of Tübingen, Elfriede-Aulhorn-Straße 5, 72076, Tübingen, Germany.
| | - Birgit Mazurek
- Tinnitus Center Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Pim van Dijk
- Department of Otorhinolaryngology/Head and Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Graduate School of Medical Sciences (Research School of Behavioural and Cognitive Neurosciences), University of Groningen, Groningen, The Netherlands
| | - Holger Schulze
- Experimental Otolaryngology, Friedrich-Alexander Universität Erlangen-Nürnberg, Waldstrasse 1, 91054, Erlangen, Germany
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Toyoda K, Yoshimura S, Fukuda-Doi M, Qureshi AI, Martin RH, Palesch YY, Ihara M, Suarez JI, Okada Y, Hsu CY, Itabashi R, Wang Y, Yamagami H, Steiner T, Sakai N, Yoon BW, Inoue M, Minematsu K, Yamamoto H, Koga M. Intensive blood pressure lowering with nicardipine and outcomes after intracerebral hemorrhage: An individual participant data systematic review. Int J Stroke 2021; 17:494-505. [PMID: 34542358 DOI: 10.1177/17474930211044635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Nicardipine has strong, rapidly acting antihypertensive activity. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine after onset of intracerebral hemorrhage on clinical outcomes were determined. METHODS A systematic review and individual participant data analysis of articles before 1 October 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving hyperacute intracerebral hemorrhage adults treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase ≥6 mL from baseline to 24-h computed tomography. SUMMARY OF REVIEW Three studies met the eligibility criteria. For 1265 patients enrolled (age 62.6 ± 13.0 years, 484 women), death or disability occurred in 38.2% and hematoma expansion occurred in 17.4%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.00-1.26 per 10 mmHg) and hematoma expansion (1.16, 1.02-1.32). Mean hourly systolic blood pressure from 1 h to any timepoint during the initial 24 h was positively associated with death or disability. Later achievement of systolic blood pressure to ≤140 mmHg increased the risk of death or disability (aOR 1.02, 95% CI 1.00-1.05 per hour). CONCLUSIONS Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h in hyperacute intracerebral hemorrhage was associated with lower risks of hematoma expansion and 90-day death or disability without increasing serious adverse events.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, USA
| | - Renee' Hebert Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yasushi Okada
- Departments of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Ryo Itabashi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Aguiar de Sousa D, Chun Y, Katan M. Joint European and World Stroke Organisation (ESO-WSO) conference highlights-2020. Clinical and Translational Neuroscience 2021. [DOI: 10.1177/2514183x21994409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite a difficult year focusing on the COVID-19 pandemic, from 7 November to 8 November, stroke clinicians and researchers experienced a great opportunity to learn about the latest research results and developments across the entire care spectrum. This year’s European and World Stroke Organisation Conference was not only the first joint conference but also the first virtual experience of this magnitude in the field. More than 5000 participants were registered worldwide. Many interesting studies and impactful large trial results were presented giving rise to lively controversies (live sessions and chats). This article will focus on a few selected studies that were presented at the conference, ranging from insights into pre-hospital triage, acute interventions, to secondary prevention, rehabilitation and the impact of the current pandemic on stroke care.
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Affiliation(s)
- Diana Aguiar de Sousa
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria (CHULN), Lisbon, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Yvonne Chun
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mira Katan
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich (ZNZ), University of Zurich, Zurich, Switzerland
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Abstract
Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120–130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24–48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.
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Affiliation(s)
- Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK.,George Institute for Global Health, Sydney, Australia
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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