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Sun P, Badihian S, Avadhani R, Walborn N, Yarava A, Alimoradi D, Awad I, Hanley D, Murthy S, Ziai W. Does stereotactic thrombolysis with alteplase for intracerebral haemorrhage alter intraventricular haematoma volume? A secondary analysis of the MISTIE-III trial. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333032. [PMID: 38670789 DOI: 10.1136/jnnp-2023-333032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/09/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Stereotactic thrombolysis reduces intracerebral haemorrhage (ICH) volume in patients with spontaneous ICH. Whether intrahaematomal alteplase administration is associated with a change in intraventricular haemorrhage volume (deltaIVH) and functional outcomes is unknown. METHODS Post hoc secondary analysis of the Minimally Invasive Surgery plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III (MISTIE-III) trial in patients with IVH on the stability CT scan. Exposure was minimally invasive surgery plus alteplase (MIS+alteplase). Primary outcome was deltaIVH defined as IVH volume on end-of-treatment CT minus IVH volume on stability CT scan. Secondary outcomes were favourable functional outcome (modified Rankin Scale 0-3) and mortality at 365 days. We assessed the relationship between MIS+alteplase and deltaIVH in the primary analysis using multivariable linear regression, and between deltaIVH and functional outcomes in secondary analyses using multiple logistic regression. RESULTS Of 499 patients in MISTIE-III, 310 (62.1%) had IVH on stability scans; mean age (SD) was 61.2±12.3 years. A total of 146 (47.1%) received the MISTIE procedure and 164 (52.9%) standard medical care (SMC) only. The MIS+alteplase group had a greater mean reduction in IVH volume compared with the SMC group (deltaIVH: -2.35 (5.30) mL vs -1.15 (2.96) mL, p=0.02). While IVH volume decreased significantly in both treatment groups, in the primary analysis, MIS+alteplase was associated with greater deltaIVH in multivariable linear regression analysis adjusted for potential confounders (β -0.80; 95% CI -1.37 to -0.22, p=0.007). Secondary analysis demonstrated no associations between IVH reduction and functional outcomes (adjusted OR (aOR) for poor outcome 1.02; 95% CI 0.96 to 1.08, p=0.61; aOR for mortality 0.99; 95% CI 0.92 to 1.06, p=0.77). CONCLUSIONS Alteplase delivered into the ICH in MISTIE-III subjects with IVH was associated with a small reduction in IVH volume. This reduction did not translate into a significant benefit in mortality or functional outcomes at 365 days. TRIAL REGISTRATION NUMBER NCT01827046.
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Affiliation(s)
- Philip Sun
- Departments of Neurology, Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shervin Badihian
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Radhika Avadhani
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nathan Walborn
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anusha Yarava
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Donya Alimoradi
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Daniel Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Santosh Murthy
- Department of Neurology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Wendy Ziai
- Departments of Neurology, Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
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Avadhani R, Ziai WC, Thompson RE, Mould WA, Lane K, Nanni A, Iacobelli M, Sharrock MF, Sansing LH, Van Eldik LJ, Hanley DF. Clinical Trial Protocol for BEACH: A Phase 2a Study of MW189 in Patients with Acute Nontraumatic Intracerebral Hemorrhage. Neurocrit Care 2024; 40:807-815. [PMID: 37919545 PMCID: PMC10959780 DOI: 10.1007/s12028-023-01867-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/22/2023] [Indexed: 11/04/2023]
Abstract
Patients with acute spontaneous intracerebral hemorrhage (ICH) develop secondary neuroinflammation and cerebral edema that can further damage the brain and lead to increased risk of neurologic complications. Preclinical studies in animal models of acute brain injury have shown that a novel small-molecule drug candidate, MW01-6-189WH (MW189), decreases neuroinflammation and cerebral edema and improves functional outcomes. MW189 was also safe and well tolerated in phase 1 studies in healthy adults. The proof-of-concept phase 2a Biomarker and Edema Attenuation in IntraCerebral Hemorrhage (BEACH) clinical trial is a first-in-patient, multicenter, randomized, double-blind, placebo-controlled trial. It is designed to determine the safety and tolerability of MW189 in patients with acute ICH, identify trends in potential mitigation of neuroinflammation and cerebral edema, and assess effects on functional outcomes. A total of 120 participants with nontraumatic ICH will be randomly assigned 1:1 to receive intravenous MW189 (0.25 mg/kg) or placebo (saline) within 24 h of symptom onset and every 12 h for up to 5 days or until hospital discharge. The 120-participant sample size (60 per group) will allow testing of the null hypothesis of noninferiority with a tolerance limit of 12% and assuming a "worst-case" safety assumption of 10% rate of death in each arm with 10% significance and 80% power. The primary outcome is all-cause mortality at 7 days post randomization between treatment arms. Secondary end points include all-cause mortality at 30 days, perihematomal edema volume after symptom onset, adverse events, vital signs, pharmacokinetics of MW189, and inflammatory cytokine concentrations in plasma (and cerebrospinal fluid if available). Other exploratory end points are functional outcomes collected on days 30, 90, and 180. BEACH will provide important information about the utility of targeting neuroinflammation in ICH and will inform the design of future larger trials of acute central nervous system injury.
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Affiliation(s)
- Radhika Avadhani
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
| | - Wendy C Ziai
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - W Andrew Mould
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
| | - Karen Lane
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
| | - Angeline Nanni
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
| | - Michael Iacobelli
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA
| | - Matthew F Sharrock
- Division of Neurocritical Care, Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren H Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Linda J Van Eldik
- Sanders-Brown Center on Aging and Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Daniel F Hanley
- BIOS Clinical Trials Coordinating Center, Johns Hopkins School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, 21202, USA.
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Kaleem S, Zhang C, Gusdon AM, Oh S, Merkler AE, Avadhani R, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Association Between Neutrophil-Lymphocyte Ratio and 30-Day Infection and Thrombotic Outcomes After Intraventricular Hemorrhage: A CLEAR III Analysis. Neurocrit Care 2024; 40:529-537. [PMID: 37349600 DOI: 10.1007/s12028-023-01774-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH) and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. We hypothesized that NLR is associated with 30-day infection and thrombotic events after ICH. METHODS We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial. The study exposure was the serum NLR obtained at baseline and on days 3 and 5. The coprimary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined through adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. RESULTS Among the 500 patients enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial, we included 303 (60.6%) without missing data on differential white blood cell counts at baseline. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR ascertained at baseline (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.07, p = 0.03) and NLR ascertained at day 3 were associated with infection (OR 1.15; 95% CI 1.05-1.20, p = 0.001) but not with thrombotic events. Conversely, NLR at day 5 was associated with thrombotic events (OR 1.07, 95% CI 1.01-1.13, p = 0.03) but not with infection (OR 1.13; 95% CI 0.76-1.70, p = 0.56). NLR at baseline was not associated with either outcome. CONCLUSIONS Serum NLR ascertained at baseline and on day 3 after randomization was associated with 30-day infection, whereas NLR obtained on day 5 was associated with thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.
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Affiliation(s)
- Safa Kaleem
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Aaron M Gusdon
- Department of Neurological Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Stephanie Oh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isaam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Harris W, Kaiser JH, Liao V, Avadhani R, Iadecola C, Falcone GJ, Sheth KN, Qureshi AI, Goldstein JN, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis. Stroke 2024; 55:541-547. [PMID: 38299346 PMCID: PMC10932908 DOI: 10.1161/strokeaha.123.045859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Nontraumatic intracerebral hemorrhage (ICH) is independently associated with a long-term increased risk of major arterial ischemic events. While the relationship between ICH location and ischemic risk has been studied, whether hematoma volume influences this risk is poorly understood. METHODS We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) trials. The exposure was hematoma volume, treated as a continuous measure in the primary analysis, and dichotomized by the median in the secondary analyses. The outcome was a symptomatic, clinically overt ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. RESULTS Of 1470 patients with ICH, the mean age was 61.7 (SD, 12.8) years, and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (interquartile range, 7.2-35.7). During a median follow-up of 107 days (interquartile range, 91-140), a total of 30 ischemic strokes occurred, of which 22 were in patients with a median ICH volume of ≥17.3 mL and a cumulative incidence of 4.6% (95% CI, 3.1-7.1). Among patients with a median ICH volume <17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7-6.0). In primary analyses using adjusted Cox regression models, ICH volume was associated with an increased risk of ischemic stroke (hazard ratio, 1.02 per mL increase [95% CI, 1.01-1.04]). In secondary analyses, ICH volume of ≥17.3 mL was associated with an increased risk of ischemic stroke (hazard ratio, 2.5 [95% CI, 1.1-7.2]), compared with those with an ICH volume <17.3 mL. CONCLUSIONS In a heterogeneous cohort of patients with ICH, initial hematoma volume was associated with a heightened short-term risk of ischemic stroke.
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Affiliation(s)
- William Harris
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Jed H. Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago, IL
| | - Daniel F. Hanley
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Wendy C. Ziai
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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Garton ALA, Oh SE, Müller A, Avadhani R, Zhang C, Merkler AE, Awad I, Hanley D, Kamel H, Ziai WC, Murthy SB. Catheter Tract Hemorrhages and Intracerebral Hemorrhage Outcomes in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial. Neurosurgery 2024; 94:334-339. [PMID: 37721435 DOI: 10.1227/neu.0000000000002687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/27/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes. METHODS We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses. RESULTS Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis. CONCLUSION Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.
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Affiliation(s)
- Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York , New York , USA
| | - Stephanie E Oh
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Achim Müller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich , Switzerland
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago , Illinois , USA
| | - Daniel Hanley
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
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Miller JL, Baschat AA, Rosner M, Blumenfeld YJ, Moldenhauer JS, Johnson A, Schenone MH, Zaretsky MV, Chmait RH, Gonzalez JM, Miller RS, Moon-Grady AJ, Bendel-Stenzel E, Keiser AM, Avadhani R, Jelin AC, Davis JM, Warren DS, Hanley DF, Watkins JA, Samuels J, Sugarman J, Atkinson MA. Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial. JAMA 2023; 330:2096-2105. [PMID: 38051327 PMCID: PMC10698620 DOI: 10.1001/jama.2023.21153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023]
Abstract
Importance Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival. Objective To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia. Design, Setting, and Participants Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies. Exposure Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age. Main Outcomes and Measures The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement. Results The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks). Conclusions and Relevance Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden. Trial Registration ClinicalTrials.gov Identifier: NCT03101891.
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Affiliation(s)
- Jena L. Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Ahmet A. Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Mara Rosner
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Yair J. Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anthony Johnson
- The Fetal Center, Department of Obstetrics and Gynecology, University of Texas Health Center, Houston
| | - Mauro H. Schenone
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | | | - Ramen H. Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Juan M. Gonzalez
- Department of Obstetrics and Gynecology, University of California, San Francisco
| | - Russell S. Miller
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Anita J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amaris M. Keiser
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland
| | - Angie C. Jelin
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan M. Davis
- Tufts Clinical and Translational Science Institute, Division of Newborn Medicine, Tufts Children’s Hospital, Tufts University, Boston, Massachusetts
| | - Daniel S. Warren
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland
| | - Joslynn A. Watkins
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua Samuels
- Division of Pediatric Nephrology and Hypertension, McGovern School at the University of Texas Health Science Center, Houston
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Meredith A. Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rivera-Lara L, Cho SM, Li Y, Ali H, McBee N, Awad IA, Avadhani R, Hanley DF, Gandhi D, Walborn N, Murthy SB, Ziai WC. Mechanistic Evaluation of Diffusion Weighted Hyperintense Lesions After Large Spontaneous Intracerebral Hemorrhage: A Subgroup Analysis of MISTIE III. Neurocrit Care 2023:10.1007/s12028-023-01890-3. [PMID: 38040993 DOI: 10.1007/s12028-023-01890-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Ischemic lesions on diffusion weighted imaging (DWI) are common after acute spontaneous intracerebral hemorrhage (ICH) but are poorly understood for large ICH volumes (> 30 mL). We hypothesized that large blood pressure drops and effect modification by cerebral small vessel disease markers on magnetic resonance imaging (MRI) are associated with DWI lesions. METHODS This was an exploratory analysis of participants in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial with protocolized brain MRI scans within 7 days from ICH. Multivariable logistic regression analysis was performed to assess biologically relevant factors associated with DWI lesions, and relationships between DWI lesions and favorable ICH outcomes (modified Rankin Scale 0-3). RESULTS Of 499 enrolled patients, 300 had MRI at median 7.5 days (interquartile range 7-8), and 178 (59%) had DWI lesions. The incidence of DWI lesions was higher in patients with systolic blood pressure (SBP) reduction ≥ 80 mm Hg in first 24 h (76%). In adjusted models, factors associated with DWI lesions were as follows: admission intraventricular hematoma volume (p = 0.03), decrease in SBP ≥ 80 mm Hg from admission to day 1 (p = 0.03), and moderate-to-severe white matter disease (p = 0.01). Patients with DWI lesions had higher odds of severe disability at 1 month (p = 0.04), 6 months (p = 0.036), and 12 months (p < 0.01). No evidence of effect modification by cerebral small vessel disease on blood pressure was found. CONCLUSIONS In patients with large hypertensive ICH, white matter disease, intraventricular hemorrhage volume, and large reductions in SBP over the first 24 h were independently associated with DWI lesions. Further investigation of potential hemodynamic mechanisms of ischemic injury after large ICH is warranted.
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Affiliation(s)
- Lucia Rivera-Lara
- Division of Stroke and Neurocritical Care, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology and Neurosurgery, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Yunke Li
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Hasan Ali
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Issam A Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Radhika Avadhani
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Gandhi
- Department of Radiology, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan Walborn
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology and Neurosurgery, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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8
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Li Y, Cho SM, Avadhani R, Ali H, Hao Y, Murthy SB, Goldstein JN, Xia F, Hu X, Ullman NL, Awad I, Hanley D, Ziai WC. Cerebral small vessel disease modifies outcomes after minimally invasive surgery for intracerebral haemorrhage. Stroke Vasc Neurol 2023:svn-2023-002463. [PMID: 37949482 DOI: 10.1136/svn-2023-002463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/29/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) for spontaneous supratentorial intracerebral haemorrhage (ICH) is controversial but may be beneficial if end-of-treatment (EOT) haematoma volume is reduced to ≤15 mL. We explored whether MRI findings of cerebral small vessel disease (CSVD) modify the effect of MIS on long-term outcomes. METHODS Prespecified blinded subgroup analysis of 288 subjects with qualified imaging sequences from the phase 3 Minimally Invasive Surgery Plus Alteplase for Intracerebral Haemorrhage Evacuation (MISTIE) trial. We tested for heterogeneity in the effects of MIS and MIS+EOT volume ≤15 mL on the trial's primary outcome of good versus poor function at 1 year by the presence of single CSVD features and CSVD scores using multivariable models. RESULTS Of 499 patients enrolled in MISTIE III, 288 patients had MRI, 149 (51.7%) randomised to MIS and 139 (48.3%) to standard medical care (SMC). Median (IQR) ICH volume was 42 (30-53) mL. In the full MRI cohort, there was no statistically significant heterogeneity in the effects of MIS versus SMC on 1-year outcomes by any specific CSVD feature or by CSVD scores (all Pinteraction >0.05). In 94 MIS patients with EOT ICH volume ≤15 mL, significant reduction in odds of poor outcome was found with cerebral amyloid angiopathy score <2 (OR, 0.14 (0.05-0.42); Pinteraction=0.006), absence of lacunes (OR, 0.37 (0.18-0.80); Pinteraction=0.02) and absence of severe white matter hyperintensities (WMHs) (OR, 0.22 (0.08-0.58); Pinteraction=0.03). CONCLUSIONS Following successful haematoma reduction by MIS, we found significantly lower odds of poor functional outcome with lower total burden of CSVD in addition to absence of lacunes and severe WMHs. CSVD features may have utility for prognostication and patient selection in clinical trials of MIS.
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Affiliation(s)
- Yunke Li
- The George Institute for Global Health, Beijing, China
| | - Sung-Min Cho
- Department of Neurology, Division of Neurocritical Care, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Radhika Avadhani
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | - Hassan Ali
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | - Yi Hao
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | - Santosh B Murthy
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fan Xia
- Department of Neurosurgery, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital of Medicine, Chengdu, Sichuan, China
| | - Natalie L Ullman
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Daniel Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | - Wendy C Ziai
- Department of Neurology, Division of Neurocritical Care, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
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9
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Carhuapoma LR, Avadhani R, Hanley DF. Who Determines the Quality of Life of Survivors of Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:309-310. [PMID: 37340237 DOI: 10.1007/s12028-023-01736-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Lourdes R Carhuapoma
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
- School of Nursing, University of Virginia, Charlottesville, VA, USA
| | | | - Daniel F Hanley
- BIOS Clinical Trials Coordinating Center, Johns Hopkins University School of Medicine, 750 East Pratt Street, 16th Floor, Baltimore, MD, USA.
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10
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Sun PY, Thompson R, Akindahunsi T, Avadhani R, Nyquist PA, Awad IA, Hanley DF, Ziai WC. Abstract WP121: Can The Extended Glasgow Outcome Scale (e-gos) Augment The Interpretation Of Results From Clinical Trials Of Minimally Invasive Surgery Of Spontaneous Intracerebral Hemorrhage Using The Modified Rankin Scale (mrs): A Secondary Analysis Of The Clear-iii And Mistie-iii Trials. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp121] [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: 02/05/2023]
Abstract
Introduction:
Currently, the modified Rankin scale (mRS) is most commonly used to assess functional outcome in clinical trials of interventions for spontaneous intracerebral hemorrhage (ICH). Extended Glasgow Outcome Score (eGOS) is often used to assess global disability/recovery after traumatic brain injury and provides additional discrimination of vegetative state (VS) from lower severe disability (LSD). We compared primary outcomes from 2 clinical trials of minimally invasive surgery for intracerebral and intraventricular hemorrhage (ICH/IVH) at different thresholds of eGOS.
Methods:
Post-hoc analysis of primary outcomes (PO) from the CLEAR-III trial (intraventricular alteplase [IVtPA] vs. saline for obstructive IVH; N=500; PO: mRS 0-3 at day 180), and MISTIE-III trial (stereotactic thrombolysis [MIS+tPA] vs. conservative management; N=499; PO: mRS 0-3 at day 365). eGOS was derived from functional outcome scales obtained during the trials. Outcomes on eGOS were categorized into 5 subgroups: good outcomes: 7-8 (A), 5-6 (B), 4 (C), and poor outcomes: 3 (D), and 1-2 (E). Generalized, ordered logistic regression analysis was performed, adjusting for age, ICH location, stability ICH and IVH volumes, and randomization GCS.
Results:
eGOS scales were available in 481 (96%) patients at day 180 in CLEAR-III and 478 (96%) patients at day 365 in MISTIE-III. In CLEAR-III, odds of being in eGOS category D (LSD) or E (death or VS) vs. the others, were approximately 40% lower for IVtPA group compared to saline group (aOR = 0.59; 95% CI, 0.38-0.90; p=0.016), and odds of being in category E (vs. the others) were almost 50% lower (aOR = 0.51; 95% CI, 0.33-0.80; p=0.004). VS occurred in 2.49% of IVtPA and 2.07% of saline group patients. In MISTIE-III, odds of being in eGOS category D or E (vs. the others) were not significantly different for MIS+tPA vs. conservative treatment: aOR = 0.84; 95% CI, 0.55-1.28; p=0.41), as were odds for being in eGOS category E (vs. the others), aOR = 0.77; 95% CI, 0.48-1.24; p=0.29).
Conclusions:
The 5-category dichotomized eGOS (4-8 vs. 1-3) defines a functional outcome improvement in CLEAR-III at day 180, which was not observed using the PO with mRS. Use of eGOS did not result in a different interpretation of the MISTIE-III trial.
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Affiliation(s)
- Philip Y Sun
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | | | | | | | | | | | - Wendy C Ziai
- JOHNS HOPKINS UNIV NEURO CRITICAL, Baltimore, MD
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11
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Kaleem S, Gusdon A, Oh S, Merkler AE, Avadhani R, Awad IA, Hanley DF, Kamel H, Ziai WC, Murthy S. Abstract TP121: Association Between Neutrophil-lymphocyte Ratio And 30-day Infection And Thrombotic Outcomes After Intracerebral Hemorrhage: A CLEAR III Analysis. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp121] [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: 02/05/2023]
Abstract
Introduction:
Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH), and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood.
Hypothesis:
NLR is associated with 30-day infection and thrombotic events after ICH.
Methods:
We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. The study exposure was the serum NLR obtained at baseline, and on days 3 and 5. The co-primary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined via adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization.
Results:
Among the 500 patients enrolled in CLEAR III, we included 228 (45.6%) with no missing data on daily NLR in the first week. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR at day 3 was associated with infection (OR, 1.2; 95% CI, 1.01-1.26), but not with thrombotic events (OR, 0.96; 95% CI, 0.85-1.10). Conversely, NLR at day 5 was associated with thrombotic events (OR, 1.2, 95% CI, 1.01-1.26), but not with infections (OR, 1.03; 95% CI, 0.94-1.14). NLR at baseline was not associated with either outcome.
Conclusions:
Serum NLR ascertained between days 3 and 5 was associated with 30-day infection and thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Wendy C Ziai
- JOHNS HOPKINS UNIV NEURO CRITICAL, Baltimore, MD
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12
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Miller JL, Baschat AA, Rosner M, Blumenfeld YJ, Moldenhauer J, Johnson A, Schenone M, Zaretsky MV, Chmait RH, Velez JG, Miller RS, Moon-Grady AJ, Bendel-Stenzel EM, Keiser A, Avadhani R, Jelin A, Davis J, Warren D, Hanley D, Atkinson M. Neonatal survival after serial amnioinfusions for fetal bilateral renal agenesis: report from the raft trial. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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13
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Kuramatsu JB, Gerner ST, Ziai W, Bardutzky J, Sembill JA, Sprügel MI, Mrochen A, Kölbl K, Ram M, Avadhani R, Falcone GJ, Selim MH, Lioutas VA, Endres M, Zweynert S, Vajkoczy P, Ringleb PA, Purrucker JC, Volkmann J, Neugebauer H, Erbguth F, Schellinger PD, Knappe UJ, Fink GR, Dohmen C, Minnerup J, Reichmann H, Schneider H, Röther J, Reimann G, Schwarz M, Bäzner H, Claßen J, Michalski D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Ishfaq MF, Chang JJ, Testai FD, Woo D, Alexandrov AV, Staykov D, Goyal N, Tsivgoulis G, Sheth KN, Awad IA, Schwab S, Hanley DF, Huttner HB. Association of Intraventricular Fibrinolysis With Clinical Outcomes in Intracerebral Hemorrhage: An Individual Participant Data Meta-Analysis. Stroke 2022; 53:2876-2886. [PMID: 35521958 PMCID: PMC9398945 DOI: 10.1161/strokeaha.121.038455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with intracerebral hemorrhage (ICH), the presence of intraventricular hemorrhage constitutes a promising therapeutic target. Intraventricular fibrinolysis (IVF) reduces mortality, yet impact on functional disability remains unclear. Thus, we aimed to determine the influence of IVF on functional outcomes. METHODS This individual participant data meta-analysis pooled 1501 patients from 2 randomized trials and 7 observational studies enrolled during 2004 to 2015. We compared IVF versus standard of care (including placebo) in patients treated with external ventricular drainage due to acute hydrocephalus caused by ICH with intraventricular hemorrhage. The primary outcome was functional disability evaluated by the modified Rankin Scale (mRS; range: 0-6, lower scores indicating less disability) at 6 months, dichotomized into mRS score: 0 to 3 versus mRS: 4 to 6. Secondary outcomes included ordinal-shift analysis, all-cause mortality, and intracranial adverse events. Confounding and bias were adjusted by random effects and doubly robust models to calculate odds ratios and absolute treatment effects (ATE). RESULTS Comparing treatment of 596 with IVF to 905 with standard of care resulted in an ATE to achieve the primary outcome of 9.3% (95% CI, 4.4-14.1). IVF treatment showed a significant shift towards improved outcome across the entire range of mRS estimates, common odds ratio, 1.75 (95% CI, 1.39-2.17), reduced mortality, odds ratio, 0.47 (95% CI, 0.35-0.64), without increased adverse events, absolute difference, 1.0% (95% CI, -2.7 to 4.8). Exploratory analyses provided that early IVF treatment (≤48 hours) after symptom onset was associated with an ATE, 15.2% (95% CI, 8.6-21.8) to achieve the primary outcome. CONCLUSIONS As compared to standard of care, the administration of IVF in patients with acute hydrocephalus caused by intracerebral and intraventricular hemorrhage was significantly associated with improved functional outcome at 6 months. The treatment effect was linked to an early time window <48 hours, specifying a target population for future trials.
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Affiliation(s)
| | - Stefan T. Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | | | | | | | - Anne Mrochen
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Kathrin Kölbl
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Malathi Ram
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, USA
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Magdy H. Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, USA
| | | | - Matthias Endres
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
- Center for Stroke Research Berlin, Germany
- German Centre for Cardiovascular Research(DZHK), Germany
- German Center for Neurodegenerative Diseases(DZNE), Germany
| | - Sarah Zweynert
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, Germany
- Department of Neurology, University of Ulm, Germany
| | - Frank Erbguth
- Department of Neurology, Nuremberg General Hospital, Germany
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany
- Department of Neurology, LVR-Hospital Bonn, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany
| | | | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany
- Department of Neurology, Klinikum Augsburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinikum Hamburg Altona, Germany
| | | | | | | | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany
| | | | - Otto W. Witte
- Department of Neurology, University of Jena, Germany
| | | | - Gerhard F. Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | | | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, USA
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
| | | | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, USA
- Second Department of Neurology, Attikon University Hospital, School of Medicine, Greece
| | - Kevin N Sheth
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, USA
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
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14
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Shah VA, Thompson RE, Yenokyan G, Acosta JN, Avadhani R, Dlugash R, McBee N, Li Y, Hansen BM, Ullman N, Falcone G, Awad IA, Hanley DF, Ziai WC. One-Year Outcome Trajectories and Factors Associated with Functional Recovery Among Survivors of Intracerebral and Intraventricular Hemorrhage With Initial Severe Disability. JAMA Neurol 2022; 79:856-868. [PMID: 35877105 PMCID: PMC9316056 DOI: 10.1001/jamaneurol.2022.1991] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients who survive severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) typically have poor functional outcome in the short term and understanding of future recovery is limited. Objective To describe 1-year recovery trajectories among ICH and IVH survivors with initial severe disability and assess the association of hospital events with long-term recovery. Design, Setting, and Participants This post hoc analysis pooled all individual patient data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 trial (CLEAR-III) and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE-III) phase 3 trial in multiple centers across the US, Canada, Europe, and Asia. Patients were enrolled from August 1, 2010, to September 30, 2018, with a follow-up duration of 1 year. Of 999 enrolled patients, 724 survived with a day 30 modified Rankin Scale score (mRS) of 4 to 5 after excluding 13 participants with missing day 30 mRS. An additional 9 patients were excluded because of missing 1-year mRS. The final pooled cohort included 715 patients (71.6%) with day 30 mRS 4 to 5. Data were analyzed from July 2019 to January 2022. Exposures CLEAR-III participants randomized to intraventricular alteplase vs placebo. MISTIE-III participants randomized to stereotactic thrombolysis of hematoma vs standard medical care. Main Outcomes and Measures Primary outcome was 1-year mRS. Patients were dichotomized into good outcome at 1 year (mRS 0 to 3) vs poor outcome at 1 year (mRS 4 to 6). Multivariable logistic regression models assessed associations between prospectively adjudicated hospital events and 1-year good outcome after adjusting for demographic characteristics, ICH and IVH severity, and trial cohort. Results Of 715 survivors, 417 (58%) were male, and the overall mean (SD) age was 60.3 (11.7) years. Overall, 174 participants (24.3%) were Black, 491 (68.6%) were White, and 49 (6.9%) were of other races (including Asian, Native American, and Pacific Islander, consolidated owing to small numbers); 98 (13.7%) were of Hispanic ethnicity. By 1 year, 129 participants (18%) had died and 308 (43%) had achieved mRS 0 to 3. In adjusted models for the combined cohort, diabetes (adjusted odds ratio [aOR], 0.50; 95% CI, 0.26-0.96), National Institutes of Health Stroke Scale (aOR, 0.93; 95% CI, 0.90-0.96), severe leukoaraiosis (aOR, 0.30; 95% CI, 0.16-0.54), pineal gland shift (aOR, 0.87; 95% CI, 0.76-0.99]), acute ischemic stroke (aOR, 0.44; 95% CI, 0.21-0.94), gastrostomy (aOR, 0.30; 95% CI, 0.17-0.50), and persistent hydrocephalus by day 30 (aOR, 0.37; 95% CI, 0.14-0.98) were associated with lack of recovery. Resolution of ICH (aOR, 1.82; 95% CI, 1.08-3.04) and IVH (aOR, 2.19; 95% CI, 1.02-4.68) by day 30 were associated with recovery to good outcome. In the CLEAR-III model, cerebral perfusion pressure less than 60 mm Hg (aOR, 0.30; 95% CI, 0.13-0.71), sepsis (aOR, 0.05; 95% CI, 0.00-0.80), and prolonged mechanical ventilation (aOR, 0.96; 95% CI, 0.92-1.00 per day), and in MISTIE-III, need for intracranial pressure monitoring (aOR, 0.35; 95% CI, 0.12-0.98), were additional factors associated with poor outcome. Thirty-day event-based models strongly predicted 1-year outcome (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.83-0.90), with significantly improved discrimination over models using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80; P < .001). Conclusions and Relevance Among survivors of severe ICH and IVH with initial poor functional outcome, more than 40% recovered to good outcome by 1 year. Hospital events were strongly associated with long-term functional recovery and may be potential targets for intervention. Avoiding early pessimistic prognostication and delaying prognostication until after treatment may improve ability to predict future recovery.
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Affiliation(s)
- Vishank A. Shah
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julian N. Acosta
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yunke Li
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The George Institute China at Peking University Health Sciences Center, Beijing, China
| | | | - Natalie Ullman
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guido Falcone
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, Chicago, Illinois
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Roh DJ, Asonye IS, Carvalho Poyraz F, Magid-Bernstein J, Joiner EF, Avadhani R, Awad I, Hanley D, Ziai WC, Murthy SB. Intraventricular Hemorrhage Expansion in the CLEAR III Trial: A Post Hoc Exploratory Analysis. Stroke 2022; 53:1847-1853. [PMID: 35086362 PMCID: PMC9133068 DOI: 10.1161/strokeaha.121.037438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes. METHODS We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses. RESULTS Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01-1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92-11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54-0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01-2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12-3.02]) but not mortality (OR, 1.40 [95% CI, 0.78-2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58-1.80]) after adjusting for similar covariates. CONCLUSIONS In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00784134.
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Affiliation(s)
- David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Ifeyinwa S. Asonye
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Fernanda Carvalho Poyraz
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jessica Magid-Bernstein
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
| | - Evan F. Joiner
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL
| | - Daniel Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY
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16
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Magid-Bernstein JR, Li Y, Cho SM, Piran PJ, Roh DJ, Gupta A, Shoamanesh A, Merkler A, Zhang C, Avadhani R, Montano N, Iadecola C, Falcone GJ, Sheth KN, Qureshi AI, Rosand J, Goldstein J, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Cerebral Microbleeds and Acute Hematoma Characteristics in the ATACH-2 and MISTIE III Trials. Neurology 2022; 98:e1013-e1020. [PMID: 34937780 PMCID: PMC8967392 DOI: 10.1212/wnl.0000000000013247] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/13/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To study the relationship between the presence of cerebral microbleeds (CMBs) and acute hematoma characteristics among patients with primary intracerebral hemorrhage (ICH). METHODS We pooled individual patient data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 (MISTIE III) trial. We included individuals with a brain MRI scan. Exposure was the presence of a CMB. The coprimary outcomes were admission ICH volume and hematoma expansion. Mixed-effects linear and logistic regression models were used, with demographics and comorbid conditions considered fixed effects and the study cohort treated as a random effect. Additional analyses assessed the relationship between CMB topography and number and hematoma characteristics. RESULTS Of the 1,499 patients with ICH enrolled in the parent trials, 466 (31.1%) were included in this analysis, and 231 (49.6%) patients had CMBs. In adjusted models, presence of CMBs was associated with smaller ICH volume (β = -0.26, 95% confidence interval [CI] -0.44 to -0.08) and lower odds of hematoma expansion (odds ratio 0.65, 95% CI 0.40-0.95; p = 0.04). The strength of association between CMBs and hematoma characteristics increased with increasing number of CMBs. The location of the CMBs and the severity of leukoaraiosis did not modify these results. DISCUSSION In a pooled cohort of patients with ICH, our results are consistent with the hypothesis that more severe underlying small vessel disease, as represented by CMBs, leads to smaller baseline hematoma volumes and reduced hematoma expansion. Underlying cerebral small vessel disease may be of prognostic significance after ICH. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT01176565 and NCT01827046. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the presence of microbleeds on MRI is associated with a smaller ICH volume at presentation and a lower rate of hematoma expansion on follow-up imaging.
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Affiliation(s)
- Jessica R Magid-Bernstein
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Yunke Li
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Sung-Min Cho
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Pirouz J Piran
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - David J Roh
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Ajay Gupta
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Ashkan Shoamanesh
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Alexander Merkler
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Cenai Zhang
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Radhika Avadhani
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Nataly Montano
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Constantino Iadecola
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Guido J Falcone
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Adnan I Qureshi
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Jonathan Rosand
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Joshua Goldstein
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Issam Awad
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Daniel F Hanley
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Hooman Kamel
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Wendy C Ziai
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China
| | - Santosh B Murthy
- From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China.
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17
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Diaz Cruz C, Porosnicu Rodriguez K, Gatti J, Zhao D, Avadhani R, Awad IA, Hanley DF, Ziai WC. Abstract TP131: Association Of Hemoglobin Over The First Week With Clinical Outcomes And Neuroimaging Characteristics In Patients With Spontaneous Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp131] [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]
Abstract
Introduction:
Studies have shown independent associations of lower admission hemoglobin (HB) levels with larger spontaneous intracerebral hemorrhage (ICH) volumes and poor outcomes, possibly mediated by hematoma expansion (HE).
Objective:
We retrospectively investigated the association of HB levels over the first week post ICH with functional outcomes (FO) and neuroimaging findings in patients with spontaneous ICH (>30 mL). We explored whether comorbidities modify the effects of HB.
Methods:
We analyzed HB levels from subjects enrolled in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial (MISTIE III). The exposure was admission HB and the HB nadir in the first week. The primary outcome was good FO at 180 days, defined as modified Rankin Scale of 0-3. Secondary outcomes were good FO at 365 days, 30-day mortality, admission ICH volume, and HE (>6 mL). Linear and logistic regression models were used to test the association of HB with clinical outcomes and neuroimaging findings. All models were adjusted for age, sex, race, treatment (medical Vs. MISTIE), Glasgow Coma Scale, ICH volume, presence of intraventricular hemorrhage, and ICH location (deep Vs. lobar). We investigated effect modification of comorbidities on association of HB with FO.
Results:
A total of 493 of 499 enrolled patients (61% males, mean age 61(SD=12) years, median ICH volume 41.8 (IQR=30.8-51.5) mL) were included. Patients with good FO at 180 days had a higher admission HB (13.2 Vs. 12.6 g/dl, p=0.001) and a higher nadir HB (11.7 Vs. 10.9 g/dl, p<0.001). In adjusted analyses, each additional g/dl in nadir HB (but not admission HB) was associated with higher odds of good FO at 180 (OR 1.29, p=0.005) and 365 (OR 1.18, P=0.048) days. Baseline (B= -1.16, p=0.02) and nadir HB (B= -1.71, p=0.001) were inversely associated with hematoma volumes, but not with HE. There was evidence of heterogeneity in the effects of diabetes on the association of nadir HB with day 180 FO (OR 0.67; p
interaction
= 0.045).
Conclusions:
In patients with ICH > 30 mL, higher nadir HB in the first week was associated with better long-term FO and smaller ICH volumes, but not with HE. Early hemoglobin changes may serve as a prognostic biomarker and a potentially modifiable factor to improve FO.
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Affiliation(s)
| | | | - John Gatti
- Johns Hopkins Sch of Medicine, Baltimore, MD
| | - David Zhao
- Johns Hopkins Sch of Medicine, Baltimore, MD
| | | | | | | | - Wendy C Ziai
- JOHNS HOPKINS UNIV NEURO CRITICAL, Baltimore, MD
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18
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Witsch J, Roh DJ, Avadhani R, Merkler AE, Kamel H, Awad I, Hanley DF, Ziai WC, Murthy SB. Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage. JAMA Netw Open 2021; 4:e2135773. [PMID: 34860246 PMCID: PMC8642781 DOI: 10.1001/jamanetworkopen.2021.35773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Intraventricular thrombolysis reduces intraventricular hemorrhage (IVH) volume in patients with spontaneous intracerebral hemorrhage (ICH), but it is unclear if a similar association with parenchymal ICH volume exists. OBJECTIVE To evaluate the association between intraventricular alteplase use and ICH volume as well as the association between a change in parenchymal ICH volume and long-term functional outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a post hoc exploratory analysis of data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 randomized clinical trial with blinded outcome assessments. Between September 1, 2009, and January 31, 2015, patients with ICH and IVH were randomized to receive either intraventricular alteplase or normal saline via an external ventricular drain. Participants with primary IVH were excluded. Data analyses were performed between January 1 and June 30, 2021. EXPOSURE Randomization to receive intraventricular alteplase. MAIN OUTCOMES AND MEASURES The primary outcome was the change in parenchymal ICH volume between the hematoma stability and end-of-treatment computed tomography scans. Secondary outcomes were a modified Rankin Scale score higher than 3 and mortality, both of which were assessed at 6 months. The association between alteplase and change in parenchymal ICH volume was assessed using multiple linear regression, whereas the associations between change in parenchymal ICH volume and 6-month outcomes were assessed using multiple logistic regression. Prespecified subgroup analyses were performed for baseline IVH volume, admission ICH volume, and ICH location. RESULTS A total of 454 patients (254 men [55.9%]; mean [SD] age, 59 [11] years) were included in the study. Of these patients, 230 (50.7%) were randomized to receive alteplase and 224 (49.3%) to receive normal saline. The alteplase group had a greater mean (SD) reduction in parenchymal ICH volume compared with the saline group (1.8 [0.2] mL vs 0.4 [0.1] mL; P < .001). In the primary analysis, alteplase use was associated with a change in the parenchymal ICH volume in the unadjusted analysis per 1-mL change (β, 1.37; 95% CI, 0.92-1.81; P < .001) and in multivariable linear regression analysis that was adjusted for demographic characteristics, stability ICH and IVH volumes, ICH location, and time to first dose of study drug per 1-mL change (β, 1.20; 95% CI, 0.79-1.62; P < .001). In the secondary analyses, no association was found between change in parenchymal ICH volume and poor outcome (odds ratio [OR], 0.97; 95% CI 0.87-1.10; P = .64) or mortality (OR, 0.97; 95% CI 0.99-1.08; P = .59). Similar results were observed in the subgroup analyses. CONCLUSIONS AND RELEVANCE This study found that intraventricular alteplase use in patients with a large IVH was associated with a small reduction in parenchymal ICH volume, but this association did not translate into improved functional outcomes or mortality. Intraventricular thrombolysis should be examined in patients with moderate to large ICH with IVH, especially in a thalamic location.
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Affiliation(s)
- Jens Witsch
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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19
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Avadhani R, Thompson RE, Carhuapoma L, Yenokyan G, McBee N, Lane K, Ostapkovich N, Stadnik A, Awad IA, Hanley DF, Ziai WC. Post-Stroke Depression in Patients with Large Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106082. [PMID: 34517296 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/30/2021] [Accepted: 08/24/2021] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To determine factors associated with post-stroke depression (PSD) and relationship between PSD and functional outcomes in spontaneous intracerebral hemorrhage (ICH) using prospective data from a large clinical trial. MATERIALS AND METHODS MISTIE III, a randomized, multicenter, placebo-controlled trial, was conducted to determine if minimally invasive surgery with thrombolysis improves outcome compared to standard medical care. Our primary outcome was post-stroke depression at 180 days. Secondary outcomes were change in blinded assessment of modified Rankin Scale (mRS) from 30 to 180 days, and from 180 to 365 days. Logistic regression models were used to assess the relationship between PSD and outcomes. RESULTS Among 379 survivors at day 180, 308 completed Center for Epidemiologic Studies Depression Scale, of which 111 (36%) were depressed. In the multivariable analysis, female sex (Adjusted Odds Ratio [AOR], 95% Confidence Interval [CI]: 1.93 [1.07-3.48]), Hispanic ethnicity (3.05 [1.19-7.85]), intraventricular hemorrhage (1.88 [1.02-3.45]), right-sided lesions (3.00 [1.43-6.29]), impaired mini mental state examination at day 30 (2.50 [1.13-5.54]), and not being at home at day 30 (3.17 [1.05-9.57]) were significantly associated with higher odds of PSD. Patients with PSD were significantly more likely to have unchanged or worsening mRS from day 30 to 180 (42.3% vs. 25.9%; p=0.004), but not from day 180 to 365. CONCLUSIONS We report high burden of PSD in patients with large volume ICH. Impaired cognition and not living at home may be more important than physical limitations in predicting PSD. Increased screening of high-risk post-stroke patients for depression, especially females and Hispanics may be warranted.
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Affiliation(s)
- Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lourdes Carhuapoma
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Noeleen Ostapkovich
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Agnieszka Stadnik
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Issam A Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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20
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Al-Kawaz MN, Li Y, Thompson RE, Avadhani R, de Havenon A, Gruber J, Awad I, Hanley DF, Ziai W. Intracranial Pressure and Cerebral Perfusion Pressure in Large Spontaneous Intracranial Hemorrhage and Impact of Minimally Invasive Surgery. Front Neurol 2021; 12:729831. [PMID: 34512537 PMCID: PMC8427275 DOI: 10.3389/fneur.2021.729831] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: We investigated the effect of hematoma volume reduction with minimally invasive surgery (MIS) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with large spontaneous intracerebral hemorrhage (ICH). Methods:Post-hoc analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE III) study, a clinical trial with blinded outcome assessments. The primary outcome was the proportion of ICP readings ≥20 and 30 mmHg, and CPP readings <70 and 60 mm Hg. Secondary outcomes included major disability (modified Rankin scale >3) and mortality at 30 and 365 days. We assessed the relationship between proportion of high ICP and low CPP events and MIS using binomial generalized linear models, and outcomes using multiple logistic regression. Results: Of 499 patients enrolled in MISTIE III, 72 patients had guideline based ICP monitors placed, 34 in the MIS group and 38 in control (no surgery) group. Threshold ICP and CPP events ≥20/ <70 mmHg occurred in 31 (43.1%) and 52 (72.2%) patients respectively. On adjusted analyses, proportion of ICP readings ≥20 and 30 mmHg were significantly lower in the MIS group vs. control group [Odds Ratio (OR) 0.27, 95% Confidence Interval [CI] 0.11–0.63 (p = 0.002); OR = 0.18, 0.04–0.75, p = 0.02], respectively. Proportion of CPP readings <70 and 60 mm Hg were also significantly lower in MIS patients [OR 0.31, 95% CI 0.15–0.63 (p = 0.001); OR 0.30, 95% CI 0.11–0.83 (p = 0.02)], respectively. Higher proportions of CPP readings <70 and 60 mm were significantly associated with short term mortality (p = 0.04), and (p = 0.006), respectively. Long term mortality was significantly associated with higher proportion of time with ICP ≥ 20 (p = 0.04), ICP ≥ 30 (p = 0.04), and CPP <70 mmHg (p = 0.01). Conclusion: Our results are consistent with the hypothesis that surgical reduction of ICH volume decreases proportion of high ICP and low CPP events and that these variables are associated with short- and long-term mortality.
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Affiliation(s)
- Mais N Al-Kawaz
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yunke Li
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Wendy Ziai
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
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21
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Al-Kawaz M, Avadhani R, Awad IA, Hanley DF, Ziai WC. Abstract P447: Intracranial Pressure and Cerebral Perfusion Pressure Monitoring in Spontaneous Intracranial Hemorrhage: A Secondary Analysis of the Mistie III Trial. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p447] [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]
Abstract
Introduction:
Intracerebral hemorrhage (ICH) management guidelines recommend maintaining intracranial pressure (ICP) <20 and cerebral perfusion pressure (CPP) between 50-70 mmHg. We did subgroup analyses of MISTIE III trial to explore whether minimally invasive surgery (MIS) improves ICP or CPP and whether thresholds are associated with long term outcomes.
Methods:
MISTIE III was a randomized clinical trial including 499 patients with spontaneous ICH randomized to MIS+Alteplase or standard medical care (SMC). Primary outcomes were any threshold event of ICP >20 and CPP <60/70 mmHg. Secondary outcomes were poor modified Rankin Scale at one year and mortality at 30/365 days. We used multivariable models to investigate factors associated with ICP/CPP events and outcomes.
Results:
Of 72 patients with ICP monitored for median 92 (72-96) hours, 31 (43.1%) had at least one ICP reading >20 and 52/35 (72.2/34.7%) had at least one CPP reading <70/60 mmHg. Lower intraventricular hemorrhage volume and SMC group were associated with having any ICP threshold event >20 and CPP event <70 mmHg whereas CPP<60 mmHg was associated with end of treatment (EOT) ICH volume, hydrocephalus on diagnostic CT and no prior antiplatelet agent use. On adjusted analyses, percentage of ICP readings >20 were significantly less likely in patients undergoing MIS vs SMC (Coefficient -0.79, 95% Confidence Interval [CI] [(-)1.46-(-)0.11]; p=0.02). Percentage of CPP readings <70 were significantly less frequent in MIS group (Coefficient -1.59 [(-)2.58-(-)0.59]; p=0.002). Patients who underwent successful MIS with EOT ICH volume <15mL also had significantly lower percentage of readings at ICP<20 (p=0.02), and CPP<70 (p=0.05). Lower percentage of CPP readings <60 mmHg was independently associated with lower mortality at 30 and 365 days (p=0.02 and 0.04) and CPP <70 was associated with lower one-year mortality (p=0.04). There were no significant associations with one-year functional outcome.
Conclusion:
Elevated ICP and inadequate CPP are not infrequent during ICP monitoring for large ICH. Burden of low CPP events predict higher short and long term mortality, but not functional outcomes. CPP may be more significant than ICP. MIS appears to mitigate ICP and CPP threshold events.
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Affiliation(s)
| | | | | | | | - Wendy C Ziai
- JOHNS HOPKINS UNIV NEURO CRITICAL, Baltimore, MD
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22
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Murthy SB, Zhang C, Gupta A, Cho SM, Rivera-Lara L, Avadhani R, Gruber J, Iadecola C, Falcone GJ, Sheth KN, Qureshi AI, Goldstein JN, Hanley DF, Kamel H, Ziai WC. Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage and Risk of Stroke: A MISTIE III and ATACH-2 Analysis. Stroke 2021; 52:595-602. [PMID: 33467877 DOI: 10.1161/strokeaha.120.031628] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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 PURPOSE Punctate ischemic lesions noted on diffusion-weighted imaging (DWI) are associated with poor functional outcomes after intracerebral hemorrhage (ICH). Whether these lesions increase long-term risk of stroke is poorly understood. METHODS We pooled individual patient data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) and the MISTIE III trial (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3). We included subjects with a magnetic resonance imaging scan. The exposure was a DWI lesion. The primary outcome was any stroke, defined as a composite of ischemic stroke or recurrent ICH, whereas secondary outcomes were incident ischemic stroke and recurrent ICH. Using multivariate Cox regression analysis, we evaluated the risk of stroke. RESULTS Of 505 patients with ICH with magnetic resonance imaging, 466 were included. DWI lesions were noted in 214 (45.9%) subjects, and 34 incident strokes (20 ischemic stroke and 14 recurrent ICH) were observed during a median follow-up of 324 days (interquartile range, 91-374). Presence of a DWI lesion was associated with a 6.9% (95% CI, 2.2-11.6) absolute increase in risk of all stroke (hazard ratio, 2.6 [95% CI, 1.2-5.7]). Covariate adjustment with Cox regression models also demonstrated this increased risk. In the secondary analyses, there was an increased risk of ischemic stroke (hazard ratio, 3.5 [95% CI, 1.1-11.0]) but not recurrent ICH (hazard ratio, 1.7 [95% CI, 0.6-5.1]). CONCLUSIONS In a heterogeneous cohort of patients with ICH, presence of a DWI lesion was associated with a 2.5-fold heightened risk of stroke among ICH survivors. This elevated risk persisted for ischemic stroke but not for recurrent ICH.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (S.B.M., C.Z., C.I., H.K.), Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (S.B.M., C.Z., C.I., H.K.), Weill Cornell Medicine, New York, NY
| | - Ajay Gupta
- Department of Radiology (A.G.), Weill Cornell Medicine, New York, NY
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (S.-M.C., L.R.-L., W.C.Z.)
| | - Lucia Rivera-Lara
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (S.-M.C., L.R.-L., W.C.Z.)
| | - Radhika Avadhani
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD (R.A., J.G., D.F.H.)
| | - Joshua Gruber
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD (R.A., J.G., D.F.H.)
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (S.B.M., C.Z., C.I., H.K.), Weill Cornell Medicine, New York, NY
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (G.J.F., K.N.S.)
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT (G.J.F., K.N.S.)
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia (A.I.Q.)
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Daniel F Hanley
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD (R.A., J.G., D.F.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (S.B.M., C.Z., C.I., H.K.), Weill Cornell Medicine, New York, NY
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD (S.-M.C., L.R.-L., W.C.Z.)
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23
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Murthy SB, Cho SM, Gupta A, Shoamanesh A, Navi BB, Avadhani R, Gruber J, Li Y, Greige T, Lioutas VA, Norton C, Zhang C, Mandava P, Iadecola C, Falcone GJ, Sheth KN, Biffi A, Rosand J, Qureshi AI, Goldstein JN, Kidwell C, Awad I, Selim M, Hanley DF, Woo D, Kamel H, Ziai WC. A Pooled Analysis of Diffusion-Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage. JAMA Neurol 2020; 77:1390-1397. [PMID: 32687564 PMCID: PMC7372494 DOI: 10.1001/jamaneurol.2020.2349] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022]
Abstract
Importance The etiology and significance of diffusion-weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. Objective To evaluate which factors are associated with DWI lesions, whether associated factors differ by ICH location, and whether DWI lesions are associated with functional outcomes. Design, Setting, and Participants This analysis pooled individual patient data from 3 randomized clinical trials (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage trial, and Intracerebral Hemorrhage Deferoxamine phase 2 trial) and 1 multicenter prospective study (Ethnic/Racial Variations of Intracerebral Hemorrhage). Patients were enrolled from August 1, 2010, to September 30, 2018. Of the 4782 patients, 1788 who underwent magnetic resonance imaging scans of the brain were included. Data were analyzed from July 1 to December 31, 2019. Main Outcomes and Measures The primary outcome consisted of factors associated with DWI lesions. Secondary outcomes were poor functional outcome, defined as a modified Rankin score (mRS) of 4 to 6, and mortality, both assessed at 3 months. Mixed-effects logistic regression was used to evaluate the association between exposures and outcomes. Subgroup analyses stratified by hematoma location were performed. Results After exclusion of 36 patients with missing data on DWI lesions, 1752 patients were included in the analysis (1019 men [58.2%]; mean [SD] age, 60.8 [13.3] years). Diffusion-weighted imaging lesions occurred in 549 patients (31.3%). In mixed-effects regression models, factors associated with DWI lesions included younger age (odds ratio [OR] per year, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.64; 95% CI, 1.17-2.30), admission systolic blood pressure (OR per 10-mm Hg increase, 1.13; 95% CI, 1.08-1.18), baseline hematoma volume (OR per 10-mL increase, 1.12; 95% CI, 1.02-1.22), cerebral microbleeds (OR, 1.85; 95% CI, 1.39-2.46), and leukoaraiosis (OR, 1.59; 95% CI, 1.67-2.17). Diffusion-weighted imaging lesions were independently associated with poor mRS (OR, 1.50; 95% CI, 1.13-2.00), but not with mortality (OR, 1.11; 95% CI, 0.72-1.71). In subgroup analyses, similar factors were associated with DWI lesions in lobar and deep ICH. Diffusion-weighted imaging lesions were associated with poor mRS in deep but not lobar ICH. Conclusions and Relevance In a large, heterogeneous cohort of prospectively identified patients with ICH, results were consistent with the hypothesis that DWI lesions represent acute sequelae of chronic cerebral small vessel disease, particularly hypertensive vasculopathy. Diffusion-weighted imaging lesions portend a worse prognosis after ICH, mainly deep hemorrhages.
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Affiliation(s)
- Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Ashkan Shoamanesh
- Population Health Research Institute, Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Joshua Gruber
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Yunke Li
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Tatiana Greige
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Casey Norton
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Pitchaiah Mandava
- Stroke Outcomes Laboratory, Department of Neurology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro Biffi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | | | | | | | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Wendy C. Ziai
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
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24
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Hansen BM, Ullman N, Muschelli J, Norrving B, Dlugash R, Avadhani R, Awad I, Zuccarello M, Ziai WC, Hanley DF, Thompson RE, Lindgren A. Relationship of White Matter Lesions with Intracerebral Hemorrhage Expansion and Functional Outcome: MISTIE II and CLEAR III. Neurocrit Care 2020; 33:516-524. [PMID: 32026447 DOI: 10.1007/s12028-020-00916-4] [Citation(s) in RCA: 5] [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: 10/25/2022]
Abstract
BACKGROUND/OBJECTIVE Intracerebral hemorrhage (ICH) patients commonly have concomitant white matter lesions (WML) which may be associated with poor outcome. We studied if WML affects hematoma expansion (HE) and post-stroke functional outcome in a post hoc analysis of patients from randomized controlled trials. METHODS In ICH patients from the clinical trials MISTIE II and CLEAR III, WML grade on diagnostic computed tomography (dCT) scan (dCT, < 24 h after ictus) was assessed using the van Swieten scale (vSS, range 0-4). The primary outcome for HE was > 33% or > 6 mL ICH volume increase from dCT to the last pre-randomization CT (< 72 h of dCT). Secondary HE outcomes were: absolute ICH expansion, > 10.4 mL total clot volume increase, and a subgroup analysis including patients with dCT < 6 h after ictus using the primary HE definition of > 33% or > 6 mL ICH volume increase. Poor functional outcome was assessed at 180 days and defined as modified Rankin Scale (mRS) ≥ 4, with ordinal mRS as a secondary endpoint. RESULTS Of 635 patients, 55% had WML grade 1-4 at dCT (median 2.2 h from ictus) and 13% had subsequent HE. WML at dCT did not increase the odds for primary or secondary HE endpoints (P ≥ 0.05) after adjustment for ICH volume, intraventricular hemorrhage volume, warfarin/INR > 1.5, ictus to dCT time in hours, age, diabetes mellitus, and thalamic ICH location. WML increased the odds for having poor functional outcome (mRS ≥ 4) in univariate analyses (vSS 4; OR 4.16; 95% CI 2.54-6.83; P < 0.001) which persisted in multivariable analyses after adjustment for HE and other outcome risk factors. CONCLUSIONS Concomitant WML does not increase the odds for HE in patients with ICH but increases the odds for poor functional outcome. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov trial-identifiers: NCT00224770 and NCT00784134.
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Affiliation(s)
- Björn M Hansen
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Natalie Ullman
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - John Muschelli
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago, Chicago, IL, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Arne Lindgren
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
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25
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Montano N, Grabarits C, Avadhani R, Goldstein JN, Mould WA, Awad IA, Hanley DF, Ziai W. Abstract 76: Non-Contrast CT Markers and Pre- and Post-Surgical Hematoma Expansion in the MISTIE III Trial Surgical Cohort. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.76] [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]
Abstract
Introduction:
A range of findings on non-contrast CT (NCCT) have been found to predict hematoma expansion after spontaneous ICH, but it is unclear whether these findings predict peri-procedural bleeding. We explored whether any specific NCCT marker(s) predict pre- or post-surgical hematoma expansion events.
Methods:
NCCTs were reviewed for presence of black hole sign, blend sign, swirl sign, and island sign in the surgical cohort from the MISTIE-III trial which evaluated minimally invasive surgery plus alteplase in ICH >30 mL. Hematoma expansion was defined as any expansion ≥6 mL or 33% ICH volume increase during pre-surgical period (Model 1) from diagnostic CT (DiagCT) to 24 hours post DiagCT and from stability CT (StabCT) to 24 hours post last dose of alteplase (Model 2). Blend sign was removed from analysis due to small sample size. Multivariable logistic regression analysis was performed to identify independent predictors of pre-op and post-op hematoma expansion.
Results:
Of 250 surgical subjects, 5 were excluded due to poor image quality. Expansion events occurred in 82 of 234 (35.0%) subjects in the pre-op interval and in 15 of 226 (7%) in the post-op interval. None of the markers were significant for pre-op expansion, but ICH volume and time from ictus to DiagCT were statistically significant predictors. Swirl sign, ICH volume, and posterior trajectory compared to lateral trajectory were independent predictors of post-op expansion events. Expansion volume pre-op and post-op were weakly associated with presence of swirl sign; Spearmans rho=0.3 p=0.065 and rho=0.60 p=0.047, respectively.
Conclusion:
This is the first analysis of impact of NCCT markers on re-bleeding post minimally invasive surgery from a large clinical trial. Despite an absence of association between NCCT markers and hematoma expansion in the pre-surgical period perhaps reflecting inclusion criteria for hemorrhage stability, swirl sign was associated with post-surgical rebleeding.
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Affiliation(s)
- Nataly Montano
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Christina Grabarits
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Radhika Avadhani
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | - W. A Mould
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Issam A Awad
- Neurology and Neurosurgery, Univ of Chicago Sch of Medicine, Baltimore, MD
| | - Daniel F Hanley
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Wendy Ziai
- Neurology and Neurosurgery, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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26
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Li Y, Cho SM, Avadhani R, Ali H, Hanley DF, Ziai WC. Abstract 7: Cerebral Small Vessel Disease Burden and Association With Post-Surgical Rebleeding and Long-Term Outcome in Intracerebral Hemorrhage Patients From the Mistie III Trial. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.7] [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]
Abstract
Objectives:
To examine the effect of cerebral small vessel disease (CSVD) markers and CSVD burden on hematoma expansion and long-term functional outcomes in large spontaneous intracerebral hemorrhage (ICH) >30 mL.
Method:
Retrospective analysis of 288 patients from the MISTIE III trial with qualified MRI sequences. MISTIE III evaluated minimally invasive surgery plus alteplase (vs medical management). We identified 6 CSVD markers including lacunes, cerebral microbleeds (CMB), enlarged perivascular space (EPVS), white matter hyperintensities (WMH), cortical superficial siderosis (cSS), and acute DWI positive lesions. First 5 components were reviewed on day 1 MRI and DWI lesions on day 7. The primary outcome was death or major disability at one year (modified Rankin score 4-6). Secondary outcome was post-surgical rebleeding, defined as symptomatic or asymptomatic hemorrhage expansion within 72 hours post last dose of alteplase.
Result:
Unfavorable outcome occurred in 65.9% at one year. Post-surgical ICH expansion occurred in 34 (22.9%) of 148 surgical patients. Mean time from symptom onset to first MRI was 0.94 (IQR 0.2-6.3) days. Most individual CSVD markers were more common in patients with unfavorable vs. favorable outcome: CMB≧5 (26.1% vs 15.0%, p=0.03), DWI lesions (65.8%vs 49.6%, p=0.006), cSS (16.8% vs 7.1%, p=0.02) severe WMH (67.7% vs 29.9%, p<0.001) severe EPVS in basal ganglia (19.3% vs 10.2%, p=0.047), and lacunes (11.2% vs 6.3%, p=0.21), In the multivariable adjusted model, cumulative CSVD score (one point for each component: CMB≥5, severe EPVS in basal ganglia, lacunes, severe WMH and cSS) was independently associated with unfavorable outcome (OR 0.56, 95%CI 0.41-0.76, p<0.001; AUC 0.855). We did not find a relationship between either independent CSVD markers or CSVD score with post-surgical ICH expansion. Cumulative CSVD score in multivariable analysis adjusted for predictors of hematoma expansion had OR 0.77 (95% CI 0.50-1.19, p=0.77; AUC 0.659).
Conclusion:
In large volume ICH patients with long-term follow-up, heavy burden of CSVD at ICH onset remains an independent predictor of unfavorable outcome, and particularly severe white matter hyperintensities. CSVD markers did not show association with post-surgical ICH expansion.
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Affiliation(s)
- Yunke Li
- Brain Injury Outcomes Cntr, Johns Hopkins Unversity, Baltimore, MD
| | - Sung-Min Cho
- Div of Neurosciences Critical Care, Johns Hopkins Unversity, Baltimore, MD
| | - Radhika Avadhani
- Brain Injury Outcomes Cntr, Johns Hopkins Unversity, Baltimore, MD
| | - Hasan Ali
- Brain Injury Outcomes Cntr, Johns Hopkins Unversity, Baltimore, MD
| | - Daniel F Hanley
- Brain Injury Outcomes Cntr, Johns Hopkins Unversity, Baltimore, MD
| | - Wendy C Ziai
- Div of Neurosciences Critical Care, Johns Hopkins Unversity, Baltimore, MD
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27
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Carhuapoma L, Avadhani R, Ostapkovich N, Lane K, McBee N, Carhuapoma JR, Ziai W, Awad I, Thompson RE, Hanley DF. Abstract 17: An Evaluation of Patient Disposition and Long-term Health-related Quality of Life In MISTIE III: Opportunities to Improve Decision Making for Critically Ill Intracerebral Hemorrhage Patients. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.17] [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]
Abstract
Introduction:
Recovery in intracerebral hemorrhage (ICH) is prolonged and unpredictable, resulting in challenges in estimating health-related quality of life (HRQoL). We describe HRQoL and patient disposition for ICH survivors with similar clinical characteristics to ICH patients who had withdrawal of life-sustaining treatment (WoLST).
Methods:
Using MISTIE III trial data (N = 499), we performed a matched cohort analysis using a published modified severity index (mSI) to compare ICH survivors (N = 379) with WoLST patients (N = 61). We used multivariable logistic regression adjusting for age, Glasgow Coma Score, deep ICH location, stability ICH and intraventricular hemorrhage volume and ≥ 3 comorbidities to create the mSI. After matching survivors with equal mSI to WoLST patients, we compared EuroQoL (EQ) visual analog scale (VAS) scores (US norm 69-76; range 0-100) by mSI quartile and patient disposition.
Results:
We matched 224 survivors to WoLST patients by mSI (range 0-6.5), with data at all timepoints. Given the large mSI range, EQ VAS scores and patient disposition were evaluated by mSI quartile groups. The median (interquartile range [IQR]) EQ VAS score increase for all mSI groups from day 30 (D30) to 180 (D180) was 20 (0-35.5,
p
< 0.0001), and 23.5 (5-40,
p
< 0.0001) for D30 to 365 (D365). The highest percentage of survivors for all mSI groups were home by D365 (G1 55%, G2 88%, G3 84.5%, G4 90%). Median (IQR) EQ VAS scores by mSI quartile, patient disposition and timepoint are reported below.
Conclusion:
ICH survivors, matching WoLST individuals, in all mSI groups demonstrated improvement in HRQoL over time, and the majority were home by D365. This study challenges current practice of identifying poor outcomes in concert with decision making employing WoLST in ICH. If goals of care are to include return to home and HRQoL, these results strongly suggest that prognostication can be improved. Prospective studies of ICH prognostication and decision making are needed.
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Affiliation(s)
- Lourdes Carhuapoma
- Anesthesiology/Critical Care Medicine, The Johns Hopkins Hosp, Baltimore, MD
| | | | | | - Karen Lane
- Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
| | - Nichol McBee
- Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
| | - Juan R Carhuapoma
- Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Univ, Baltimore, MD
| | - Wendy Ziai
- Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Daniel F Hanley
- Neurology and Anesthesiology/Critical Care Medicine, Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
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28
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Ostapkovich N, Avadhani R, Carhuapoma L, Thompson RE, Lane K, McBee N, Ziai W, Awad I, Hanley D. Abstract 12: An Evaluation of Functional Outcome at 1 Year of Poor Prognosis Patients in Mistie-III. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.12] [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]
Abstract
Introduction:
Clinical factors impacting prognosis following Intracerebral Hemorrhage (ICH) have been well described in the literature, with “poor” prognosis often leading to withdrawing life sustaining treatments (WoLST). The MISTIE-III trial data provides an opportunity to review 12 month outcome of “poor" prognosis subjects.
Methods:
In order to evaluate functional recovery of ICH survivors compared with patients who had WoLST we used a severity index (SI) score for predicting good functional recovery 1 year following ICH. The SI used 6 clinical univariate variables from the MISTIE-III analysis (age
>
67, Glasgow Coma Score [GCS]
<
8, deep ICH location, stability ICH volume
>
45mL, stability intraventricular hemorrhage (IVH) volume>0.4mL) and
>
3 comorbidities (hypertension, hyperlipidemia, cardiovascular disease, and end-stage renal disease). Based on the SI scores for subjects who had WoLST, a matched cohort of survivors with “poor" prognosis (mRS 4-5) were tracked for functional recovery for 12 months.
Results:
Of the participants enrolled in MSITIE-III, 61 had WoLST. Of the non-WoLST ICH survivors, 16 progressed to death during the acute period. Another 48 had died prior to the 1 year (D365) follow up. At the 30 Day (D30) evaluation, there were 263 ICH survivors with “poor" prognosis SI scores having a mRS of 4 or 5 and 94% were still in a treatment facility. By D365, 47% of the “poor prognosis” patients had improved to mRS 0-3 (good outcome) with 98% living at home. Of the remaining, 36% had a mRS of 4 (moderately severe disability) with 64% living at home, and 17% had a mRS of 5 (severe disability) with 31% living at home.
Conclusion:
For family members of patients sustaining an ICH where clinical factors indicate a “poor" prognosis, the decision to continue or withdraw life sustaining treatment is difficult. Our data shows that ICH patients with clinical factors that are assumed to indicate “poor" prognosis for recovery can, when given time, achieve a favorable outcome.
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Affiliation(s)
| | | | | | | | - Karen Lane
- Neurology, Johns Hopkins Univ, Baltimore, MD
| | | | - Wendy Ziai
- Anes and Neuro Anesthesiology, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery and Neurology, Univ of Chicago, ChIcago, IL
| | - Dan Hanley
- Neurology, Johns Hopkins Univ, Baltimore, MD
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29
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Murthy SB, Cho SM, Gupta A, Shoamanesh A, Avadhani R, Gruber J, Greige T, Lioutas VA, Norton C, Mandava P, Falcone GJ, Sheth KN, Qureshi AI, Goldstein JN, Kidwell C, Selim M, Woo D, Kamel H, Ziai WC, Hanley DF. Abstract 18: Diffusion Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage: A Pooled Analysis of Individual Patient Data From MISTIE-III, ATACH-II, I-DEF, and ERICH. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.18] [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]
Abstract
Introduction:
The etiology and significance of diffusion weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. We evaluated which factors were associated with DWI lesions, whether associated factors differed by ICH location, and whether DWI lesions were associated with functional outcomes.
Methods:
We pooled individual patient data from the MISTIE III trial, the ATACH-II trial, the i-DEF trial, and the ERICH study. We included only patients who underwent protocolized magnetic resonance imaging (MRI) of the brain. A poor functional outcome was defined as a modified Rankin Scale (mRS) score of 4-6 at 3-6 months. We used mixed effects logistic regression with the study database as a random effect.
Results:
Among 1,775 ICH patients, there were 621 (35.6%) lobar, 978 (55.9%) deep, and 148 (8.5%) infratentorial ICHs. Median time to MRI scan was 1.5 days (IQR, 1-4). DWIHLs occurred in 559 (31.5%) patients, with 190 (34.3%) in lobar ICH and 320 (57.8%) in deep ICHs. In mixed effects regression models, factors associated with DWIHLs included younger age factors associated with DWIHLs after acute ICH included younger age (OR, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.59; 95% CI, 1.18-2.16), admission systolic blood pressure (SBP per 10 mm Hg, OR, 1.13; 95% CI, 1.05-1.22), cerebral microbleeds (OR, 1.71, 95% CI, 1.24-2.35), and leukoaraiosis (OR, 1.60; 95% CI, 1.14-2.25). Patients with DWIHLs had higher odds of mRS 4-6 (OR, 1.57; 95% CI, 1.24-1.99) compared to those without, after adjustment for demographics and ICH severity. In subgroup analyses, similar factors influenced DWIHLs in deep ICH. However, in lobar ICH, younger age, admission SBP, and leukoaraiosis were associated with DWIHLs. Presence of DWIHLs was independently associated with poor mRS in deep ICH but not in lobar ICH. There was no relationship between acute BP lowering and DWIHLs, regardless of location.
Conclusions:
In a large, heterogeneous cohort of ICH patients, our results are consistent with the hypothesis that DWIHLs represent the effects of chronic hypertensive vasculopathy and acute blood pressure elevation. Furthermore, DWIHLs portend poor prognosis after ICH, particularly in deep hemorrhages.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Sung-Min Cho
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Ajay Gupta
- Radiology, Weill Cornell Medicine, New York, NY
| | | | | | - Joshua Gruber
- Johns Hopkins Universtiy Sch of Medicine, Baltimore, MD
| | | | | | | | - Pitchaiah Mandava
- Michael E. DeBakey VA Med Cntr/ Baylor College of Medicine, Houston, TX
| | | | | | | | | | | | | | | | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Wendy C Ziai
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Daniel F Hanley
- Brain Injury Outcomes Cntr, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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Cho SM, Murthy S, Li Y, Ali H, Avadhani R, Hanley D, Ziai W. Abstract TMP19: MRI Characteristics and Predictors of Diffusion Weighted Hyperintense Lesions After Spontaneous Intracerebral Hemorrhage: A Secondary Analysis of MISTIE-III. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp19] [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]
Abstract
Introduction:
Mechanisms of diffusion weighted hyperintense lesions (DWIHL) after spontaneous intracerebral hemorrhage (ICH) are controversial. We evaluated mechanism and outcome of DWIHL.
Methods:
Protocolized MRI scans within 7 days from ICH were reviewed from MISTIE-III trial. Imaging analysis included DWIHL, leukoariosis (Fazekas score), enlarged perivascular space (EPVS), and cerebral microbleeds. Multivariable logistic regression analysis was performed to assess predictors and outcomes of having DWIHLs. Favorable outcome was defined as modified Rankin Score 0-3 at 12 months.
Results:
Of 499 patients, 300 underwent DWI studies (62% lobar ICH; 38% deep ICH) and 178 (59%) had acute DWIHLs (66% lobar; 34% deep). DWIHL locations were perihematomal in 140 (79%); and remote in 96 (54%). In multivariable regression analysis, DWIHLs were associated with initial mean arterial pressure [MAP] (odds ratio [OR]: 1.004; 95% confidence interval [CI]: 1.002-1.01), initial ICH volume (OR: 1.004; 95%CI: 1.001-1.01), NIHSS at randomization (OR: 1.01; 95%CI: 1.01-1.02), hypertension history (OR: 1.41; 95%CI: 1.04-1.93), and Fazekas score (OR: 1.04; 95%CI: 1.01-1.08). Patients with DWIHLs were less likely to have favorable outcome (66% vs. 50%; OR: 0.89; 95%CI: 0.81-0.99) after adjusting for ICH severity; however, the presence of DWIHLs did not confer an independent mortality risk at 12 months. In addition, perihematomal DWIHLs were associated with ICH volume (OR: 1.003; 95%CI: 1.00-1.01), NIHSS (OR: 1.01; 95%CI: 1.00-1.02), deep location (OR: 1.25; 95%CI: 1.10-1.42), and centrum semiovale EPVS score (OR: 0.99; 95% CI: 0.99-1.00). Remote DWIHLs were associated with Fazekas score (OR: 1.17; 95%CI: 1.06-1.29), centrum semiovale EPVS score (OR: 1.01; 95%CI: 1.00-1.01), atrial fibrillation (OR: 1.40; 95%CI: 1.04-1.90), and maximal ΔMAP on first 24 hours (OR: 1.004; 95%CI: 1.001-1.006).
Conclusions:
DWIHLs were common (59%) in patients after spontaneous ICH, predominantly in lobar locations and were associated with unfavorable neurologic outcome. While perihematomal DWIHLs were associated with ICH severity, remote DWIHLs suggested different mechanisms including acute blood pressure reduction, cardiac emboli, and white matter disease severity.
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Affiliation(s)
| | - Santosh Murthy
- Dept of Neurology and Feil Family Brain and Mind Rsch Institute, Weill Cornell Medicine, New York, NY
| | - Yunke Li
- Johns Hopkins Univ, Baltimore, MD
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Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ, Gandhi D, Mould WA, Ullman N, Ali H, Carhuapoma JR, Kase CS, Lees KR, Dawson J, Wilson A, Betz JF, Sugar EA, Hao Y, Avadhani R, Caron JL, Harrigan MR, Carlson AP, Bulters D, LeDoux D, Huang J, Cobb C, Gupta G, Kitagawa R, Chicoine MR, Patel H, Dodd R, Camarata PJ, Wolfe S, Stadnik A, Money PL, Mitchell P, Sarabia R, Harnof S, Barzo P, Unterberg A, Teitelbaum JS, Wang W, Anderson CS, Mendelow AD, Gregson B, Janis S, Vespa P, Ziai W, Zuccarello M, Awad IA. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019; 393:1021-1032. [PMID: 30739747 PMCID: PMC6894906 DOI: 10.1016/s0140-6736(19)30195-3] [Citation(s) in RCA: 447] [Impact Index Per Article: 89.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. METHODS MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. FINDINGS Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). INTERPRETATION For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. FUNDING National Institute of Neurological Disorders and Stroke and Genentech.
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Affiliation(s)
- Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Richard E Thompson
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Rosenblum
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - W Andrew Mould
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hasan Ali
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alastair Wilson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Joshua F Betz
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Yi Hao
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David LeDoux
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Judy Huang
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cully Cobb
- Mercy Neurological Institute Stroke Center, Sacramento, California, USA
| | - Gaurav Gupta
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ryan Kitagawa
- University of Texas, McGovern Medical Center, Houston, TX, USA
| | | | | | - Robert Dodd
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Stacey Wolfe
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | | | | | | | - Pal Barzo
- University of Szeged, Szeged, Hungary
| | | | - Jeanne S Teitelbaum
- Montreal Neurological Institute and Hospital at McGill University, Montreal, QC, Canada
| | - Weimin Wang
- Guangzhou Neuroscience Institute, Guangzhou Liuhua Qiao Hospital, Guangzhou, China
| | - Craig S Anderson
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Scott Janis
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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Mould WA, Muschelli J, Avadhani R, McBee N, Lane K, Thompson R, Ziai W, Zuccarello M, Awad I, Hanley DF. Abstract 15: Reduction in Perihematomal Edema Leads to Improved Clinical Outcomes: Results from the MISTIE III Trial. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - John Muschelli
- Johns Hopkins Bloomberg Sch of Public Health, Baltimore, MD
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Avadhani R, Thompson RE, Yenokyan G, Lane K, McBee N, Ziai WC, Awad IA, Hanley DF. Abstract WP556: Predicting Modified Rankin Scale Using Prior Cognition Measure: Results From CLEAR III Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp556] [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]
Abstract
Introduction:
Intraventricular hemorrhage (IVH) is a subtype of intracerebral hemorrhage (ICH) accounting for 50% mortality and serious survivor disability. We examined whether screening Mini-Mental State Examination (MMSE) scores assessed at days 30 and/or 180 could predict good functional outcome, measured by modified Rankin Scale (mRS) at days 180 and 365 post-stroke.
Methodology:
CLEAR III was a multicenter, randomized, phase III trial that tested the benefits of accelerated IVH clot removal. Patients were followed for one year with MMSE and mRS collected at days 30 (D30), 180 (D180) and 365 (D365). Good functional outcome was defined as mRS 0-3. Of 500 patients randomized, 354 known survivors were analyzed. Multivariate logistic regression (MLR) was used to estimate the relationship between good D180 and D365 mRS and D30 and/or D180 MMSE adjusting for age and any ICH location.
Results:
The model predicted a 15% increase in the odds of good D180 mRS for each unit increase in D30 MMSE (OR [95% CI] =1.15 [1.11, 1.20], p-value<0.001). Based on this model, a score of MMSE of 14 or higher is associated with good D180 mRS with 77% sensitivity, 75% specificity, and 76% correctly classified cases (AUC=0.84). In MLR model, D30 MMSE (AOR [95% CI]=1.14 [1.10, 1.19], p-value<0.001) and thalamus ICH location (AOR [95% CI]=0.18 [0.09, 0.38], p-value<0.001) were significant predictors of good D180 mRS, with no significant association with age (AOR [95% CI]=0.97 [0.94, 1.00], p-value=0.073). Similarly, we saw a 14% increase (AOR [95% CI]=1.14, [1.09, 1.20], p-value<0.001) in the odds of good D365 mRS for each unit increase in D30 MMSE, and 9% increase (AOR [95% CI]=1.09, [1.03, 1.15], p-value=0.002) in the odds of good D365 mRS for each unit increase in D180 MMSE (p-value <0.001, AUC=0.88). D30 MMSE (AOR [95% CI]=1.12 [1.06, 1.18], p-value<0.001), D180 MMSE (AOR [95% CI]=1.12 [1.05, 1.19], p-value=0.001), age (AOR [95% CI]=0.96 [0.92, 1.00], p-value=0.041), and thalamus ICH location (AOR [95% CI]=0.17 [0.07, 0.44], p-value<0.001) were significantly associated with good D365 mRS.
Conclusion:
Cognition measurements, such as MMSE, may be helpful in predicting good functional outcomes at D180 and D365 post-stroke.
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Affiliation(s)
- Radhika Avadhani
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Richard E Thompson
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Gayane Yenokyan
- Dept of Biostatistics, Johns Hopkins Bloomberg Sch of Public Health, Baltimore, MD
| | - Karen Lane
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Nichol McBee
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Wendy C Ziai
- Dept of Neurology - Div of Neurosciences Critical Care, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Issam A Awad
- Dept of Neurological Surgery, Univ of Chicago Medicine, Chicago, IL
| | - Daniel F Hanley
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
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Casella JF, Adams RJ, Brambilla DJ, Strouse JJ, Maier P, Dlugash R, Avadhani R, Vermillion K, Tonascia J, Voeks JH, Hanley DF, Thompson RE, Lehmann HP. Developing a risk-based composite neurologic outcome for a trial of hydroxyurea in young children with sickle cell disease. Clin Trials 2018; 16:20-31. [PMID: 30426764 DOI: 10.1177/1740774518807160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Studies of interventions to prevent the many neurological complications of sickle cell disease must take into account multiple outcomes of variable severity, with limited sample size. The goals of the studies presented were to use investigator preferences across outcomes to determine an attitude-based weighting of relevant clinical outcomes and to establish a valid composite outcome for a clinical trial. METHODS In Study 1, investigators were surveyed about their practice regarding hydroxyurea therapy and opinions about outcomes for the "Hydroxyurea to Prevent the Central Nervous System Complications of Sickle Cell Disease Trial" (HU Prevent), and their minimally acceptable relative risk reduction for the two outcome components, motor and neurocognitive deficits. In Study 2, HU Prevent investigators provided overall weights for these two components. In Study 3, they provided more granular rankings, ratings, and maximum number acceptable to harm. A weighted composite outcome, the Stroke Consequences Risk Score, was constructed that incorporates the major neurologic complications of sickle cell disease. The Stroke Consequences Risk Score represents the 3-year risk of suffering the adverse consequences of stroke. In Study 4, the results of the Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP2) and Silent Infarct Transfusion Trials were reanalyzed in light of the composite outcome. RESULTS In total, 22 to 27 investigators participated per study. In Study 1, across three samplings between 2009 and 2015, the average minimally acceptable relative risk reduction ranged from 0.36 to 0.50, at or below the target effect size of 0.50. In 2015, 21 (91%) reported that a placebo-controlled trial is reasonable; 23 (100%), that it is ethical; and 22 (96%), that they would change their practice, if the results of the trial were positive. In Studies 2 and 3, the weight elicited for a cognitive decline (of 10 IQ points) from the overall assessment was 0.67 (and for motor deficit, the complementary 0.33); from ranking, 0.6; from rating, 0.58; and from maximal number acceptable to harm, 0.5. Using data from two major clinical trials, Study 4 demonstrated the same conclusions as the original trials using the Stroke Consequences Risk Score, with smaller p-values for both reanalyses. An assessment of acceptability was performed as well. CONCLUSION This set of studies provides the rationale, justification, and validation for the use of a weighted composite outcome and confirms the need for the phase III HU Prevent study. Surveys of investigators in multi-center studies can provide the basis of clinically meaningful outcomes that foster the translation of study results into practice while increasing the efficiency of a study.
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Affiliation(s)
- James F Casella
- 1 Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert J Adams
- 2 Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | | | - John J Strouse
- 1 Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,4 Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pia Maier
- 5 Heidelberg University School of Medicine, Heidelberg, Germany
| | - Rachel Dlugash
- 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Radhika Avadhani
- 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - James Tonascia
- 7 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jenifer H Voeks
- 2 Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Daniel F Hanley
- 8 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Thompson
- 7 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Harold P Lehmann
- 9 Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lane K, Keita M, Avadhani R, Dlugash R, Mayo S, Thompson RE, Awad I, McBee N, Ziai W, Hanley DF. African American Screening and Enrollment in (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III) CLEAR III. Clin Res (Alex) 2018; 32:https://www.acrpnet.org/2018/08/14/african-american-screening-and-enrollment-in-the-clear-iii-trial/. [PMID: 30221183 PMCID: PMC6138411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Under-enrolling minority patients in clinical trials reduces generalizability. CLEAR III, a randomized controlled trial, presented an opportunity to assess African American (AA) participation. METHODS AA enrollment was compared to U.S. population and NINDS trial data then stratified by region; census data for 42 recruitment cities were compared to screening and randomization percentages, using simple linear regression. RESULTS AAs were 25% of screens and 45.1% of enrollments (n=370), more than twice the 19.8% participation rate reported by the 2011 NINDS Advisory Panel on Health Disparities Research and triple the projected 13.9% 2014 U.S. population. Conversion rates were (AA vs. non-AA): overall (8.7% vs. 3.4%, p<0.001); Northeast (7.7% vs. 2.9%, p<0.001); South (8.2% vs. 4.0%, p<0.001); Midwest (10.3% vs. 3.6%, p<0.01); and West (8.9% vs. 3.8%, p=0.02). AA enrollments ranged from 0% to 100% (mean: 40.4%). AA screening ranged from 0% to 63.7% (mean: 23.2%). AA city census ranged from 1.3% to 82.7% (mean: 28.0%); higher census was associated with higher screening (p<0.0001) and enrollment (p=0.004). CONCLUSIONS AAs were willing to enroll in an acute stroke trial. AA city census rates should be considered when selecting enrollment centers and setting recruitment goals. Factors leading to successful AA recruitment should be further investigated, as population-based participation is a goal in all trials.
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Affiliation(s)
- Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maningbe Keita
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven Mayo
- Emissary International, LLC, Austin, TX, USA
| | | | - Issam Awad
- University of Chicago Medicine and Biological Sciences, Chicago, IL, USA 60637
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Baker AD, Rivera Perla KM, Yu Z, Dlugash R, Avadhani R, Mould WA, Ziai W, Thompson RE, Staykov D, Hanley DF. Fibrinolytic for treatment of intraventricular hemorrhage: A meta-analysis and systematic review. Int J Stroke 2017; 13:11-23. [PMID: 28920538 DOI: 10.1177/1747493017730745] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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 Intraventricular hemorrhage is a significant cause of mortality and morbidity worldwide. Treating intraventricular hemorrhage with intraventricular fibrinolytic therapy via a catheter is becoming an increasingly utilized intervention. Aims This meta-analysis aimed to investigate the role of intraventricular fibrinolytic treatment in hypertensive intraventricular hemorrhage patients and evaluate the effect sizes for survival as well as level of function at differing time points. Summary of review PubMed, CNKI, VIP, and Wanfang were searched using the terms "IVH" and "IVH and ICH" for human studies with adult patients published between January 1950 and July 2016. Seventeen publications were selected. Data analysis showed lower rates of mortality in the treatment group at 30 days ( P < 0.001), 180 days ( P = 0.001), 365 days ( P = 0.40), and overall ( P < 0.001). Pooling modified Rankin Scale and Glasgow outcome scale data, the treatment group had more good functional outcomes at 30 days ( P = 0.38), 90 days ( P = 0.04), 180 days ( P = 0.31), 365 days ( P = 0.76), and overall ( P = 0.02). Good functional outcome was defined as modified Rankin Scale score of 0 to 3 or a Glasgow outcome scale score of 3 to 5. Conclusions Intraventricular fibrinolytic for treatment of hypertensive intraventricular hemorrhage reduces mortality and potentially leads to an increased number of good functional outcomes. Different functional outcome scales (modified Rankin Scale or Glasgow outcome scale) produce different effect sizes. Intraventricular fibrinolytic treatment may offer intraventricular hemorrhage patients a targeted therapy that produces meaningful mortality benefit and possible functional outcome benefits.
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Affiliation(s)
- Alexandra Delaney Baker
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | | | - Zhiyuan Yu
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA.,2 Department of Neurosurgery, Sichuan University, West China School of Medicine, Chengdu, China
| | - Rachel Dlugash
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - William Andrew Mould
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Wendy Ziai
- 3 Department of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Richard E Thompson
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Dimitre Staykov
- 4 Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Daniel F Hanley
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
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Chittle MD, Rao SK, Jaff MR, Patel VI, Gallen KM, Avadhani R, Ferris TG, Wasfy JH. Asynchronous vascular consultation via electronic methods: A feasibility pilot. Vasc Med 2015; 20:551-6. [PMID: 26385414 DOI: 10.1177/1358863x15601734] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.
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Affiliation(s)
- Melissa D Chittle
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sandhya K Rao
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael R Jaff
- Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA
| | - Virendra I Patel
- Division of Vascular and Endovascular surgery, Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M Gallen
- Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Boston, MA, USA Division of Vascular and Endovascular surgery, Paul and Phyllis Fireman Vascular Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Radhika Avadhani
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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