Long-Term Antithyroid Drug Treatment: A Systematic Review and Meta-Analysis

Objectives: Trends in serum thyroid-stimulating hormone (TSH) and TSH receptor antibody (TRAb) changes during antithyroid drug treatment, and long-term prognosis were evaluated in Graves’ hyperthyroidism (GD). Methods: In 609 GD patients initially treated with 15 mg of methyl-mercapto imidazole (MMI), the changes in serum TRAb and long-term prognosis were compared in the TSH-normalized group (A) and the TSH-suppressed group (B and C) during the initial 180 days of treatment. Results: Early responses to MMI during 180 days of treatment were as follows: 48 cases (7.9%) became hypothyroid with elevated TSH (A1), and 188 cases (30.9%) became euthyroid with normal TSH (A2). Among patients with continuously suppressed TSH, the free T4 (fT4) level was low in 31 cases (5.1%) (B1-inappropriately suppressed TSH), fT4 and fT3 were normal in 185 cases (30.4%) (B2), fT4 was normal, but fT3 remained high in 84 cases (13.8%) (B3), and fT4 remained high in 73 cases (12.0%) (C-refractory). Serum TRAb became negative after < 5 years then remained negative in 25% - 51% of the cases (smooth type), became negative after < 5 years then became positive again in 30% - 43% of the cases (fluctuating type), and remained positive after > 5 years in 10% - 42% of the cases (smoldering type). In total, remission occurred after 6.2 (3.0 - 10.4) years of treatment in 42%, possible remission on a small maintenance dosage of antithyroid drug occurred in 13%, and spontaneous hypothyroidism occurred in 4.4% of the cases. The smoldering type was more frequent in the B1 and C groups than in others, and remission was less frequent. The difference in the long-term prognosis depending on the early response to MMI disappeared after excluding the ablated patients. Without ablation, remission or spontaneous hypothyroidism could be expected in 60% - 75% of patients after tenacious treatment for > 10 years. Conclusions: Prolonged suppression of serum TSH may suggest active TRAb activity during treatment, and continuous TRAb positivity for more than 5 years suggests persistent GD activity.

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INCIDENCE OF REMISSION AFTER ANTITHYROID DRUG TREATMENT IN GRAVES' DISEASE

Acta Endocrinologica ◽

10.1530/acta.0.061s173 ◽

1969 ◽

Vol 61 (1_Suppl) ◽

pp. S173

Author(s):

J. A. Wils ◽

P. W. C. Kloppenborg

Keyword(s):

Drug Treatment ◽

Antithyroid Drug ◽

Graves Disease ◽

Antithyroid Drug Treatment

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Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds19126 ◽

2019 ◽

Vol 24 (5) ◽

pp. 558-571 ◽

Cited By ~ 3

Author(s):

Kartik Bhatia ◽

Hans Kortman ◽

Christopher Blair ◽

Geoffrey Parker ◽

David Brunacci ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Meta Analysis ◽

Case Series ◽

Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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