Significance of endoscopic hematoma evacuation in elderly patients with spontaneous putaminal hemorrhage

Background: The efficacy of endoscopic surgery for spontaneous intracerebral hemorrhages (ICH) has been previously reported, but differences in the effect between early and late elderlies remain unclear. Methods: Ninety-seven patients diagnosed with putaminal hemorrhage (age, ≥65 years; hematoma volume, ≥30 mL) were included in this retrospective analysis and separated into three treatment groups: craniotomy surgery (CR), endoscopic surgery (EN), and non-surgical (NS) groups. The patients were additionally subdivided into two groups according to age: patients aged 65–74 years (“early elderlies”) and patients aged ≥75 years (“late elderlies”). Their clinical data and outcomes at discharge were compared using statistical analyses. Results: The CR and the EN groups were associated with lower mortality rates (P < 0.001), lower modified Rankin Scale (mRS; P = 0.007), and lower National Institutes of Health Stroke Scale (NIHSS; P = 0.029) compared to the NS group. Early elderlies in the CR and EN groups with ICH scores of 3 also had significantly better outcomes (P = 0.001). The proportion of patients with mRS ≤ 4 was highest in the early elderlies of the EN group (P = 0.553). Although significant differences in the change of NIHSS scores between the early and late elderlies was not observed, significantly improved NIHSS scores were observed in the EN group compared to the NS group, even in the late elderlies (P = 0.037). Conclusion: The evacuation of deep-seated intracranial hematomas using the endoscope might improve functional outcomes and mortality, regardless of age.

Download Full-text

ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2014-011125.rep ◽

2018 ◽

Vol 10 (Suppl 1) ◽

pp. i4-i7 ◽

Cited By ~ 17

Author(s):

Aquilla S Turk ◽

Don Frei ◽

David Fiorella ◽

J Mocco ◽

Blaise Baxter ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Nihss Score ◽

First Pass ◽

Procedural Complications ◽

Intracerebral Hemorrhages ◽

Stent Retrievers ◽

A New Technique

BackgroundThe development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization.Methods98 prospectively identified acute ischemic stroke patients with 100 occluded large cerebral vessels at six institutions were included in the study. The ADAPT technique was utilized in all patients. Procedural and clinical data were captured for analysis.ResultsThe aspiration component of the ADAPT technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 95%. The average time from groin puncture to at least TICI 2b recanalization was 37 min. A 5MAX demonstrated similar success to a 5MAX ACE in achieving TICI 2b/3 revascularization alone (75% vs 82%, p=0.43). Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 17.0 (12.0–21.0) and improved to a median NIHSS score at discharge of 7.3 (1.0–11.0). Ninety day functional outcomes were 40% (modified Rankin Scale (mRS) 0–2) and 20% (mRS 6). There were two procedural complications and no symptomatic intracerebral hemorrhages.DiscussionThe ADAPT technique is a fast, safe, simple, and effective method that has facilitated our approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.

Download Full-text

Adiposity and Outcome After Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.027900 ◽

2021 ◽

Vol 52 (1) ◽

pp. 144-151

Author(s):

Zuolu Liu ◽

Nerses Sanossian ◽

Sidney Starkman ◽

Gilda Avila-Rinek ◽

Marc Eckstein ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Odds Ratio ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Related Quality ◽

Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

Download Full-text

Mortality Rate and Functional Outcomes Among Patients Presenting with Anticoagulation- Associated Intracranial Hemorrhage

Blood ◽

10.1182/blood-2020-138469 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 24-25

Author(s):

Sujitha Srinathan ◽

Christopher Cipkar ◽

Philip Chiang ◽

Lana A Castellucci

Keyword(s):

Atrial Fibrillation ◽

Mortality Rate ◽

Hospital Mortality ◽

Functional Outcomes ◽

Oral Anticoagulants ◽

Mortality Rates ◽

Clinical Impact ◽

Modified Rankin Scale ◽

Hospital Data ◽

Ottawa Hospital

Background Oral anticoagulants are the recommended therapy for prophylaxis and treatment of venous thromboembolism and for stroke prevention among patients with non-valvular atrial fibrillation. Given their widespread use, clinicians must balance efficacy and anticoagulation associated bleeding risks. Intracranial hemorrhage (ICH) has been the most feared complication, as this form of bleeding has been associated with the greatest morbidity and mortality. Clinical trials suggest a lower incidence of ICH among patients prescribed the direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs). While reassuring, the clinical impact on functional outcomes once an anticoagulant-associated ICH does occur is needed. The aim of this study was to evaluate the role of anticoagulation use on in-hospital mortality rates, and functional outcomes among survivors presenting with ICH. Methods In this study, we present data from a retrospective chart review of patients who presented to The Ottawa Hospital, Ottawa, Canada with ICH between January 2016 and December 2017. Patients were identified from the Ottawa Hospital Data Warehouse using ICD-10 codes. Patient demographics, type of anticoagulant/antiplatelet agent and indication for therapy were collected. The primary outcome was in-hospital mortality rates among patients prescribed oral anticoagulants compared with those not anticoagulated or on antiplatelet therapy. A secondary outcome was functional assessment of survivors at hospital discharge using the modified Rankin Scale (mRS), a validated tool used widely in contemporary stroke research to measure the degree of disability after a neurological event. Results 1457 patients were identified in the Ottawa Hospital Data and 1331 patients with ICH were confirmed by manual review. 195 patients were on an oral anticoagulant, and the primary indication for anticoagulation was atrial fibrillation (Table 1). Intraparenchymal bleeding was most common among patients on DOACs, while patients on warfarin tended to have more subdural hematomas (Table 2). In-hospital mortality was 37.7% in DOAC-related ICH, 36.4% in warfarin-related ICH and 16.8% in patients not on an antithrombotic therapy. The average modified Rankin Scale (excluding death as a competing factor) at the time of discharge was 3.4 in DOAC-related ICH, 3.6 in warfarin-related ICH and 3.2 in patients not on an anticoagulant or antiplatelet (Table 3). The majority of patients with a DOAC-related ICH were on Apixaban or Rivaroxaban. The in-hospital mortality for patients on Apixaban (N=31) and Rivaroxaban (N=39) was 29.0% and 46.2%, respectively (Table 4). Conclusions In this cohort of patients presenting with ICH to a large academic hospital, the in-hospital mortality rate was higher in patients receiving oral anticoagulation compared to those not on anticoagulants. DOAC-related ICH tended to have similar in-hospital mortality when compared to warfarin; however, among survivors, functional outcomes at discharge tended to be more favourable in the DOAC cohort. Although the DOACs are reported in the literature to have an overall lower incidence of ICH, prospective studies are needed to understand the clinical impact when a bleeding event does occur. Disclosures Castellucci: Servier: Honoraria; Bayer: Honoraria; BMS-Pfizer: Honoraria; LEO Pharma: Honoraria.

Download Full-text

Mechanical thrombectomy with second-generation devices for acute cerebral middle artery M2 segment occlusion: A meta-analysis

Interventional Neuroradiology ◽

10.1177/1591019919886405 ◽

2019 ◽

Vol 26 (2) ◽

pp. 187-194 ◽

Cited By ~ 1

Author(s):

Guangshuo Li ◽

Rui Huang ◽

Weishuai Li ◽

Xiaotian Zhang ◽

Guorong Bi

Keyword(s):

Ischemic Stroke ◽

Functional Outcomes ◽

Second Generation ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Mortality Rates ◽

Functional Independence ◽

Intracerebral Hematoma ◽

Modified Rankin Scale ◽

Significant Difference

Background The benefit of mechanical thrombectomy for an acute ischemic stroke involving M2 segment occlusion is not clear, especially when performed with second-generation thrombectomy devices. Method We reviewed the literature to investigate clinical outcomes and the rates of recanalization, symptomatic intracerebral hematoma, and mortality in mechanical thrombectomy performed using second-generation thrombectomy devices. We compared the outcomes between patients treated for M2 and M1 occlusions. Results Seven studies involving 805 patients with M2 thrombectomy were included in this meta-analysis. The functional independence rate 90 days after thrombectomy (modified Rankin Scale 0–2) was 59.3% (OR 1.81, 95% CI 1.74–1.88). The recanalization rate (thrombolysis in cerebral infarction 0–2) was 84.16% (OR 2.32, 95% CI 2.08–2.29). The symptomatic intracerebral hematoma rate was 4.9% (OR 1.05, 95% CI 1.03–1.09). The mortality was 7.7% (OR 1.08, 95% CI 1.03–1.13). The outcomes were better in patients with M2 occlusion than in those with M1 occlusion. In a subgroup analysis, we found that among patients with hypertension, mechanical thrombectomy achieved better functional outcomes and recanalization in M2 occlusion than M1 occlusion. Conclusion Mechanical thrombectomy performed with second-generation thrombectomy devices for M2 occlusion can provide a good functional outcome as well as satisfying recanalization. Moreover, there was no significant difference in the symptomatic intracerebral hematoma and mortality rates, suggesting this procedure is as safe in M2 occlusion as in M1 occlusion.

Download Full-text

General Anesthesia Versus Conscious Sedation and Local Anesthesia During Thrombectomy for Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.120.028963 ◽

2020 ◽

Vol 51 (7) ◽

pp. 2036-2044 ◽

Cited By ~ 6

Author(s):

Manuel Cappellari ◽

Giovanni Pracucci ◽

Stefano Forlivesi ◽

Valentina Saia ◽

Sergio Nappini ◽

...

Keyword(s):

General Anesthesia ◽

Scale Score ◽

Local Anesthesia ◽

Functional Outcomes ◽

Randomized Clinical Trials ◽

Conscious Sedation ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose: As numerous questions remain about the best anesthetic strategy during thrombectomy, we assessed functional and radiological outcomes in stroke patients treated with thrombectomy in presence of general anesthesia (GA) versus conscious sedation (CS) and local anesthesia (LA). Methods: We conducted a cohort study on prospectively collected data from 4429 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Results: GA was used in 2013 patients, CS in 1285 patients, and LA in 1131 patients. The rates of 3-month modified Rankin Scale score of 0–1 were 32.7%, 33.7%, and 38.1% in the GA, CS, and LA groups: GA versus CS: odds ratios after adjustment for unbalanced variables (adjusted odds ratio [aOR]), 0.811 (95% CI, 0.602–1.091); and GA versus LA: aOR, 0.714 (95% CI, 0.515–0.990). The rates of modified Rankin Scale score of 0–2 were 42.5%, 46.6%, and 52.4% in the GA, CS, and LA groups: GA versus CS: aOR, 0.902 (95% CI, 0.689–1.180); and GA versus LA: aOR, 0.769 (95% CI, 0.566–0.998). The rates of 3-month death were 21.5%, 19.7%, and 14.8% in the GA, CS, and LA groups: GA versus CS: aOR, 0.872 (95% CI, 0.644–1.181); and GA versus LA: aOR, 1.235 (95% CI, 0.844–1.807). The rates of parenchymal hematoma were 9%, 12.6%, and 11.3% in the GA, CS, and LA groups: GA versus CS: aOR, 0.380 (95% CI, 0.262–0.551); and GA versus LA: aOR, 0.532 (95% CI, 0.337–0.838). After model of adjustment for predefined variables (age, sex, thrombolysis, National Institutes of Health Stroke Scale, onset-to-groin time, anterior large vessel occlusion, procedure time, prestroke modified Rankin Scale score of <1, antiplatelet, and anticoagulant), differences were found also between GA versus CS as regards modified Rankin Scale score of 0–2 (aOR, 0.659 [95% CI, 0.538–0.807]) and GA versus LA as regards death (aOR, 1.413 [95% CI, 1.095–1.823]). Conclusions: GA during thrombectomy was associated with worse 3-month functional outcomes, especially when compared with LA. The inclusion of an LA arm in future randomized clinical trials of anesthesia strategy is recommended.

Download Full-text

Primary intraventricular hemorrhage outcomes in the CLEAR III trial

International Journal of Stroke ◽

10.1177/1747493020908146 ◽

2020 ◽

Vol 15 (8) ◽

pp. 872-880

Author(s):

Sarah E Nelson ◽

W Andrew Mould ◽

Dheeraj Gandhi ◽

Richard E Thompson ◽

Sarah Salter ◽

...

Keyword(s):

Barthel Index ◽

Intraventricular Hemorrhage ◽

National Institutes Of Health ◽

Clot Lysis ◽

Modified Rankin Scale ◽

Long Term Outcomes ◽

Treatment Groups ◽

Inverse Probability Weighted ◽

Regression Adjustment

Background Intraventricular hemorrhage occurs due to intracerebral hemorrhage with intraventricular extension or without apparent parenchymal involvement, known as primary intraventricular hemorrhage. Aims We evaluated the prognosis of primary intraventricular hemorrhage patients in the CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage). Methods In patients with primary intraventricular hemorrhage versus those with secondary intraventricular hemorrhage, we compared intraventricular alteplase response and outcomes including modified Rankin Scale, Barthel Index, National Institutes of Health Stroke Scale (NIHSS), and extended Glasgow Outcome Scale (eGOS) at 30, 180, and 365 days. Outcomes were also compared in primary intraventricular hemorrhage patients who received intraventricular alteplase versus placebo (normal saline) and in matched primary and secondary intraventricular hemorrhage patients using inverse-probability-weighted regression adjustment. Results Of 500 patients enrolled in CLEAR III, 46 (9.2%) had primary intraventricular hemorrhage. Combining both treatment groups, primary intraventricular hemorrhage patients had larger intraventricular hemorrhage volumes (median: 34.2 mL vs. 20.8 mL, p < 0.01) but similar intraventricular hemorrhage removal (51.0% vs. 59.0%, p = 0.24) compared to secondary intraventricular hemorrhage patients, respectively. Confirming previous studies, primary intraventricular hemorrhage patients achieved better NIHSS, modified Rankin Scale, Barthel Index, and eGOS scores at days 30, 180, and 365, respectively (all p < 0.01), although mortality was similar to secondary intraventricular hemorrhage patients; matching analysis yielded similar results. Primary intraventricular hemorrhage patients who received intraventricular alteplase ( n = 19) and saline ( n = 27) achieved similar outcomes. Conclusions In CLEAR III, primary intraventricular hemorrhage patients who survived achieved better long-term outcomes than surviving secondary intraventricular hemorrhage patients with similar mortality. Outcomes and safety were similar between primary intraventricular hemorrhage patients receiving alteplase and those receiving saline.

Download Full-text

Platelet Endothelial Aggregation Receptor 1 Polymorphism Is Associated With Functional Outcome in Small-Artery Occlusion Stroke Patients Treated With Aspirin

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.664012 ◽

2021 ◽

Vol 8 ◽

Author(s):

Zhizhang Li ◽

Huayu Jiang ◽

Ying Ding ◽

Dong Zhang ◽

Xiaoguang Zhang ◽

...

Keyword(s):

Functional Outcomes ◽

Regression Models ◽

Artery Occlusion ◽

National Institutes Of Health ◽

Nucleotide Polymorphism ◽

Small Artery ◽

Stroke Patients ◽

Single Nucleotide ◽

Treatment Groups ◽

Small Artery Occlusion

Background: The role of genetic polymorphisms is important in defining the patient's prognosis and outcomes in coronary artery disease. The present study aimed to explore the association between platelet endothelial aggregation receptor 1 (PEAR1) rs12041331 polymorphism and the outcomes in patients with acute ischemic stroke treated with aspirin or dual antiplatelet therapy (DAPT) with clopidogrel.Methods: A total of 868 ischemic stroke patients admitted to our hospital from January 1, 2016 to December 30, 2018 were retrospectively studied. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification defined stroke subtypes. These patients were treated with aspirin alone or DAPT. The genotype distribution of PEAR1 rs12041331 single-nucleotide polymorphism (AA, AC, and CC) between different TOAST subtypes and treatment groups was assessed, and the clinical impact of genetic variants on functional outcomes defined by the National Institutes of Health Stroke Scale, modified Rankin Scale, and Barthel Index was analyzed using univariate and multivariate logistic regression models.Results: Among the 868 stroke patients, the PEAR1 AA genotype was 16%, GA was 47%, and GG was 36%. Forty-four percent had aspirin alone, and 56% had DAPT. Overall, the distribution of PEAR single-nucleotide polymorphism was not significant among the two treatment groups or subtypes of TOAST. In contrast, in patients treated with aspirin alone, PEAR1 AA tended to be higher in the small-artery occlusion (SAO) subtype when compared with the no-lacunar subtype, including cardioembolism and large-artery atherosclerosis. PEAR1 AA genotype was significantly associated with favorable functional outcomes at day 7 and discharge only in SAO patients treated with aspirin alone compared with the GG genotype. Multivariate regression models further suggested that AA genotype was independently associated with favorable outcomes in this group after being adjusted for three common stroke risk factors such as age, hypertension history, and C-reactive protein level [odds ratio (OR) 0.23, 95% confidence interval (CI), 0.07–0.64, P = 0.02 for 7-day National Institutes of Health Stroke Scale; OR 0.2, 95% CI, 0.06–0.66, P = 0.03 for 7-day modified Rankin Scale, and OR 0.25, 95% CI, 0.08–0.72, P = 0.03 for 7-day Barthel Index, respectively].Conclusion: The impact of PEAR1 rs12041331 polymorphism on aspirin depends on the TOAST subtype. PEAR1 AA carrier with SAO stroke is most sensitive to aspirin therapy. PEAR1 AA is an independent factor for the short-term functional outcomes in SAO patients treated with aspirin alone.Clinical Registration Number: 1800019911.

Download Full-text

Interval between endoscopic surgery and decreased intracranial pressure related to putaminal hemorrhage prognosis

Surgical Neurology International ◽

10.25259/sni_236_2019 ◽

2020 ◽

Vol 11 ◽

pp. 78

Author(s):

Hiroki Uchikawa ◽

Shigeo Yamashiro ◽

Yasuyuki Hitoshi ◽

Makoto Yoshikawa ◽

Akimasa Yoshida ◽

...

Keyword(s):

Intracranial Pressure ◽

Endoscopic Surgery ◽

Treatment Time ◽

Operation Time ◽

Hematoma Volume ◽

Neurological Outcomes ◽

Evacuation Rate ◽

Time Operation ◽

Early Peak ◽

Putaminal Hemorrhage

Background: Endoscopic evacuation of a putaminal hemorrhage is effective and minimally invasive; however, it may not result in sufficient brain decompression. While monitoring postoperative intracranial pressure (ICP) is likely useful, specific ICP data in patients with a putaminal hemorrhage are limited. The aim of this study was to determine the association between postoperative ICP and the prognosis of patients with putaminal hemorrhage after endoscopic surgery. Methods: We retrospectively analyzed 24 consecutive patients with a putaminal hemorrhage in whom ICP monitoring after endoscopic surgery was performed. Clinical data regarding hematoma volume, evacuation rate, onset-to-treatment time, operation time, ICP max, ICP peak out time (T peak out), and neurological outcomes on discharge were investigated. Results: From August 2011 to October 2015, 24 patients with a putaminal hemorrhage were analyzed. Consciousness on admission and hemorrhage volume were associated with poor outcomes after endoscopic surgery for putaminal hemorrhage. The hematoma volume, operation time, and evacuation rate of hemorrhage were correlated to early peak out of ICP. Furthermore, a T peak out ≤24 h was significantly associated with good neurological outcomes on discharge. Conclusions: Our data suggest that early peak out (≤24 h) of ICP after endoscopic surgery is predictive of a good prognosis following putaminal hemorrhage. Operation time and evacuation rate of hemorrhage could hasten peak out of ICP and improve outcomes in patients with a putaminal hemorrhage after endoscopic surgery.

Download Full-text

Hemodynamic Status During Endovascular Stroke Treatment: Association of Blood Pressure with Functional Outcome

Neurocritical Care ◽

10.1007/s12028-021-01229-w ◽

2021 ◽

Author(s):

Min Chen ◽

Dorothea Kronsteiner ◽

Johannes Pfaff ◽

Simon Schieber ◽

Laura Jäger ◽

...

Keyword(s):

Blood Pressure ◽

Standard Deviation ◽

Functional Outcome ◽

Scale Score ◽

Endovascular Therapy ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Vessel Occlusion ◽

Stroke Treatment ◽

The Mean

Abstract Background Optimal blood pressure (BP) management during endovascular stroke treatment in patients with large-vessel occlusion is not well established. We aimed to investigate associations of BP during different phases of endovascular therapy with reperfusion and functional outcome. Methods We performed a post hoc analysis of a single-center prospective study that evaluated a new simplified procedural sedation standard during endovascular therapy (Keep Evaluating Protocol Simplification in Managing Periinterventional Light Sedation for Endovascular Stroke Treatment). BP during endovascular therapy in patients was managed according to protocol. Data from four different phases (baseline, pre-recanalization, post recanalization, and post intervention) were obtained, and mean BP values, as well as changes in BP between different phases and reductions in systolic BP (SBP) and mean arterial pressure (MAP) from baseline to pre-recanalization, were used as exposure variables. The main outcome was a modified Rankin Scale score of 0–2 three months after admission. Secondary outcomes were successful reperfusion and change in the National Institutes of Health Stroke Scale score after 24 h. Multivariable linear and logistic regression models were used for statistical analysis. Results Functional outcomes were analyzed in 139 patients with successful reperfusion (defined as thrombolysis in cerebral infarction grade 2b–3). The mean (standard deviation) age was 76 (10.9) years, the mean (standard deviation) National Institutes of Health Stroke Scale score was 14.3 (7.5), and 70 (43.5%) patients had a left-sided vessel occlusion. Favorable functional outcome (modified Rankin Scale score 0–2) was less likely with every 10-mm Hg increase in baseline (odds ratio [OR] 0.76, P = 0.04) and pre-recanalization (OR 0.65, P = 0.011) SBP. This was also found for baseline (OR 0.76, P = 0.05) and pre-recanalization MAP (OR 0.66, P = 0.03). The maximum Youden index in a receiver operating characteristics analysis revealed an SBP of 163 mm Hg and MAP of 117 mm Hg as discriminatory thresholds during the pre-recanalization phase to predict functional outcome. Conclusions In our protocol-based setting, intraprocedural pre-recanalization BP reductions during endovascular therapy were not associated with functional outcome. However, higher intraprocedural pre-recanalization SBP and MAP were associated with worse functional outcome. Prospective randomized controlled studies are needed to determine whether BP is a feasible treatment target for the modification of outcomes.

Download Full-text

Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

Journal of Neurosurgery ◽

10.3171/2016.9.jns161301 ◽

2018 ◽

Vol 128 (1) ◽

pp. 120-125 ◽

Cited By ~ 24

Author(s):

Robert F. Spetzler ◽

Joseph M. Zabramski ◽

Cameron G. McDougall ◽

Felipe C. Albuquerque ◽

Nancy K. Hills ◽

...

Keyword(s):

Ruptured Aneurysm ◽

Modified Rankin Scale ◽

Clinical Trial Registration ◽

Treatment Groups ◽

Significant Difference ◽

Initial Hospitalization ◽

Intent To Treat ◽

Post Hoc ◽

Saccular Aneurysms

OBJECTIVEThe Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions.METHODSThe primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment.RESULTSOf the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10).CONCLUSIONSIn the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

Download Full-text