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Polster SP, Carrión-Penagos J, Lyne SB, Gregson BA, Cao Y, Thompson RE, Stadnik A, Girard R, Money PL, Lane K, McBee N, Ziai W, Mould WA, Iqbal A, Metcalfe S, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Zuccarello M, Mendelow AD, Hanley DF, Awad IA. Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials. Neurosurgery 2021; 88:961-970. [PMID: 33475732 DOI: 10.1093/neuros/nyaa572] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 06/30/2020] [Accepted: 11/12/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. OBJECTIVE To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. METHODS Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n = 84) were compared to STICH II all lobar cases (n = 259) for volumetric analyses. All MISTIE III surgical patients (n = 240) were compared to both STICH I and II (n = 722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. RESULTS End-of-treatment ICH volume ≤28.8 mL in MISTIE III and ≤30.0 mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180 d (P = .01 and P = .003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180 d with STICH I and II (P = .0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. CONCLUSION Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, UK
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ahmed Iqbal
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Stephen Metcalfe
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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Menacho ST, Grandhi R, Delic A, Anadani M, Ziai WC, Awad IA, Hanley DF, de Havenon A. Impact of Intracranial Pressure Monitor-Guided Therapy on Neurologic Outcome After Spontaneous Nontraumatic Intracranial Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105540. [PMID: 33360250 PMCID: PMC8080544 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105540] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 10/28/2020] [Accepted: 12/05/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Intracranial pressure (ICP) monitors have been used in some patients with spontaneous intracranial hemorrhage (ICH) to provide information to guide treatment without clear evidence for its use in this population. We assessed the impact of ICP monitor placement, including external ventricular drains and intraparenchymal monitors, on neurologic outcome in this population. MATERIALS AND METHODS In this secondary analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation III trial, the primary outcome was poor outcome (modified Rankin Scale score 4-6) and the secondary outcome was death, at 1 year from onset. We compared outcomes in patients with or without an ICP monitor using unadjusted and adjusted logistic regression models. The analyses were repeated in a balanced cohort created with propensity score matching. RESULTS Seventy patients underwent ICP monitor placement and 424 did not. Poor outcome was seen in 77.1% of patients in the ICP-monitor subgroup compared with 53.8% in the no-monitor subgroup (p<0.001). Of patients in the ICP-monitor subgroup, 31.4% died, compared with 21.0% in the no-monitor subgroup (p=0.053). In multivariate models, ICP monitor placement was associated with a >2-fold greater risk of poor outcome (odds ratio 2.76, 95% CI 1.30-5.85, p=0.008), but not with death (p=0.652). Our findings remained consistent in the propensity score-matched cohort. CONCLUSION These results question whether ICP monitor-guided therapy in patients with spontaneous nontraumatic ICH improves outcome. Further work is required to define the causal pathway and improve identification of patients that might benefit from invasive ICP monitoring.
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Affiliation(s)
- Sarah T Menacho
- Departments of Neurosurgery, University of Utah, Salt Lake City, UT, USA.
| | - Ramesh Grandhi
- Departments of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Alen Delic
- Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Mohammad Anadani
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Wendy C Ziai
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Issam A Awad
- Department of Neurosurgery, The University of Chicago School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam de Havenon
- Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
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