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Ali M, Ascanio LC, Smith C, Odland I, Murtaza-Ali M, Vasan V, Downes M, Schuldt BR, Lin A, Dullea J, Schupper AJ, Hardigan T, Asghar N, Mocco J, Kellner CP. Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes. J Neurointerv Surg 2024; 16:994-1004. [PMID: 37620128 DOI: 10.1136/jnis-2023-020787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton Riley Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Lin
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hollingworth M, Woodhouse LJ, Law ZK, Ali A, Krishnan K, Dineen RA, Christensen H, England TJ, Roffe C, Werring D, Peters N, Ciccone A, Robinson T, Członkowska A, Bereczki D, Egea-Guerrero JJ, Ozturk S, Bath PM, Sprigg N. The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial. Neurosurgery 2024; 95:605-616. [PMID: 38785451 PMCID: PMC11302947 DOI: 10.1227/neu.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set. METHODS Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not. RESULTS Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P -value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P -value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P -value = .45). CONCLUSION TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.
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Affiliation(s)
- Milo Hollingworth
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhe K. Law
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Azlinawati Ali
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Faculty of Health Sciences, School of Medical Imaging, University of Sultan Zainal Abidin, Kuala Nerus, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Robert A. Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Timothy J. England
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, UK
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle under Lyme, UK
| | - David Werring
- Stroke Research Centre, Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Nils Peters
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alfonso Ciccone
- Azienda Socio Sanitaria Territoriale di Mantova, Mantova, Italy
| | | | | | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Serefnur Ozturk
- Department of Neurology, Neurointensive Care- Stroke Center, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
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Cui M, Tang X, Xiong W, Deng Y, Yang Q. Feasibility Study of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage with Large Hematoma: a Comparison with Craniotomy Using Propensity Score Matching Analysis. Neurocrit Care 2024:10.1007/s12028-024-02085-0. [PMID: 39192100 DOI: 10.1007/s12028-024-02085-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 07/26/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) with large hematomas is commonly treated with craniotomy combined with decompressive craniectomy, procedures that involve huge trauma and require subsequent cranioplasty. Recently, endoscopic surgery has shown significant promise in treating ICH, but its feasibility for large hematomas remains uncertain. Therefore, this study aims to compare endoscopic surgery with craniotomy and to evaluate the efficacy and safety of endoscopic surgery in treating large hematomas ICH. METHODS A retrospective analysis was conducted on the clinical data from patients with spontaneous supratentorial ICH and hematoma volumes exceeding 50 mL who underwent either endoscopic surgery or craniotomy. Propensity score matching analysis was employed to reduce selection bias. The efficacy and safety of endoscopic surgery were evaluated by analyzing blood loss, postoperative edema, mortality rate, complications, and the Glasgow Outcome Scale (GOS) at 6-month follow-up. RESULTS A total of 113 cases that met the criteria were collected, with 65 in the endoscopic surgery group and 48 in the craniotomy group. After propensity score matching, each group contained 34 cases. The mean hematoma volume was 64.84 ± 11.02 mL in the endoscopy group and 66.57 ± 12.77 mL in the craniotomy group (p = 0.554). Hematoma evacuation rates were 93.27% in the endoscopy group and 89.34% in the craniotomy group (p = 0.141). The endoscopy group exhibited lower blood loss, shorter surgical time, and reduced postoperative edema volume at 24 h compared to the craniotomy group. The rate of pulmonary infection was slightly lower in the endoscopy group compared to the craniotomy group (70.59% vs. 91.18%, p = 0.031), but there were no statistically significant differences in overall complications and mortality rate between the two groups. GOS scores were similar in both groups at the 6-month follow-up. CONCLUSIONS Endoscopic surgery is safe and feasible for treating spontaneous supratentorial ICH with large hematomas, demonstrating efficacy similar to that of craniotomy with decompressive craniectomy.
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Affiliation(s)
- Min Cui
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - XiaoYong Tang
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - WeiMing Xiong
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - YongBing Deng
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Qiang Yang
- Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China.
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Morris NA, Simard JM, Chaturvedi S. Surgical Management for Primary Intracerebral Hemorrhage. Neurology 2024; 103:e209714. [PMID: 39074339 DOI: 10.1212/wnl.0000000000209714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
The incidence of primary intracerebral hemorrhage (ICH) is increasing, particularly in younger patients, in part, because of increased prescription of anticoagulants. The ICH incidence rate from 2016 to 2018 in the United States was nearly 79 per 100,000 person-years and as high as 367 per 100,000 person-years among those 75 years or older. Worldwide, ICH comprises 28% of all new strokes, but a higher disease burden than ischemic stroke because of its higher morbidity and mortality. While mortality seems to be decreasing, functional outcomes are not improving. After negative trials of open surgical evacuation, recent trials of medical management strategies including intensive blood pressure control and prothrombotic agents intended to reduce hematoma expansion failed to demonstrate efficacy. Concomitantly, continued interest in minimally invasive surgical approaches arose from appreciation of secondary iatrogenic injury incurred to subcortical white matter tracts from open surgical techniques. A positive trial of minimally invasive surgery for lobar hemorrhage has recently been reported, bringing new optimism and demanding a reconsideration of surgical management of ICH. In this narrative review, we summarize the landmark studies, review recent literature, and consider the outstanding questions surrounding surgical management of ICH.
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Affiliation(s)
- Nicholas A Morris
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - J Marc Simard
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
| | - Seemant Chaturvedi
- From the Departments of Neurology & Program in Trauma (N.A.M.), Neurosurgery (J.M.S.), and Neurology & Stroke Program (S.C.), University of Maryland School of Medicine, Baltimore
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Marti-Fabregas J, Ramos-Pachón A, Prats-Sanchez L, Núñez-Guillén A, Rodríguez BL, Rodriguez-Luna D, Amaro S, Silva Y, Rodriguez-Campello A, Puig I, Gomez-Choco M, Vázquez-Justes D, Guanyabens N, Cocho D, Cánovas D, Steinhauer EG, Llull L, Guasch-Jiménez M, Martinez-Domeño A, Marin R, Lambea-Gil Á, Díaz GE, Paipa-Merchan A, Quesada H, Casadevall MP, Wenger D, Pancorbo O, Seró L, Pérez J, Costa X, Zaragoza J, Rodríguez-Villatoro N, Catena E, Calvo NM, Krupinski J, De La Ossa NP, Abilleira S, Salvat-Planas M, Fagundez O, Camps-Renom P. Influence of Hospital Type on Outcomes of Patients With Acute Spontaneous Intracerebral Hemorrhage: A Population-Based Study. Neurology 2024; 103:e209539. [PMID: 38875516 DOI: 10.1212/wnl.0000000000209539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Whether the outcome of patients with spontaneous intracerebral hemorrhage (ICH) differs depending on the type of hospital where they are admitted is uncertain. The objective of this study was to determine influence of hospital type at admission (telestroke center [TSC], primary stroke center [PSC], or comprehensive stroke center [CSC]) on outcome for patients with ICH. We hypothesized that outcomes may be better for patients admitted to a CSC. METHODS This is a multicenter prospective observational and population-based study of a cohort of consecutively recruited patients with ICH (March 2020-March 2022). We included all patients with spontaneous ICH in Catalonia (Spain) who had a pre-ICH modified Rankin scale (mRS) score of 0-3 and who were admitted to the hospital within 24 hours of onset. We compared patients admitted to a TSC/PSC (n = 641) or a CSC (n = 1,320) and also analyzed the subgroup of patients transferred (n = 331) or not transferred (n = 310) from a TSC/PSC to a CSC. The main outcome was the 3-month mRS score obtained by blinded investigators. Outcomes were compared using adjusted ordinal logistic regression to estimate the common odds ratio (OR) and 95% CI for a shift in mRS scores. A propensity score matching (PSM) analysis was performed for the subgroup of transferred patients. RESULTS Relevant data were obtained from 1961 of a total of 2,230 patients, with the mean (SD) age of 70 (14.1) years, and 713 (38%) patients were women. After adjusting for confounders (age, NIH Stroke Scale score, intraventricular hemorrhage, hematoma volume, and pre-ICH mRS score), type of hospital of initial admission (CSC vs TSC/PSC) was not associated with outcome (adjusted common OR 1.13, 95% CI 0.93-1.38). A PSM analysis indicated that transfer to a CSC was not associated with more favorable outcomes (OR 0.77, 95% CI 0.55-1.10; p = 0.16). DISCUSSION In this population-based study, we found that, after adjusting for confounders, hospital types were not associated with functional outcomes. In addition, for patients who were transferred from a TSC/PSC to a CSC, PSM indicated that outcomes were similar to nontransferred patients. Our findings suggest that patient characteristics are more important than hospital characteristics in determining outcome after ICH. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03956485.
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Affiliation(s)
- Joan Marti-Fabregas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Anna Ramos-Pachón
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Luis Prats-Sanchez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Ana Núñez-Guillén
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Blanca Lara Rodríguez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Rodriguez-Luna
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sergio Amaro
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Yolanda Silva
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Ana Rodriguez-Campello
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Isabel Puig
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Manuel Gomez-Choco
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Daniel Vázquez-Justes
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Nicolau Guanyabens
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Dolores Cocho
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - David Cánovas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Eva Giralt Steinhauer
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Laura Llull
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Marina Guasch-Jiménez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Alejandro Martinez-Domeño
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Rebeca Marin
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Álvaro Lambea-Gil
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Garbiñe Ezcurra Díaz
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Andrés Paipa-Merchan
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Helena Quesada
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Marc Puig Casadevall
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Denisse Wenger
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Olalla Pancorbo
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Laia Seró
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jordi Pérez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Xavier Costa
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jose Zaragoza
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Esther Catena
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Núria Matos Calvo
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Jerzy Krupinski
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Natalia Pérez De La Ossa
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Planas
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Olga Fagundez
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Pol Camps-Renom
- From the Department of Neurology (J.M.-F., A.R.-P., L.P.-S., M.G.-J., A.M.-D., R.M., Á.L.-G., G.E.D., P.C.-R.), Hospital de la Santa Creu i Sant Pau, Barcelona; Department of Neurology (A.N.-G., B.L.R., A.P.-M., H.Q.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat; Department of Neurology (D.R.-L.), Hospital Vall d'Hebron, Barcelona; Department of Neurology (S. Amaro, L.L.), Hospital Clínic Barcelona; Department of Neurology (Y.S., M.P.C.), Hospital Universitari Dr Josep Trueta, Girona; Department of Neurology (A.R.-C., E.G.S.), Hospital del Mar, Barcelona; Department of Neurology (I.P., D.W., N.P.D.L.O., O.F.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (M.G.-C.), Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí; Department of Neurology (D.V.-J.), Hospital Universitari Arnau de Vilanova, Lleida; Department of Neurology (N.G.), Consorci Sanitari del Maresme, Mataró; Department of Neurology (D. Cocho), Hospital General de Granollers, Granollers; Department of Neurology (D. Cánovas), Hospital Universitari Parc Taulí, Sabadell; Department of Neurology (O.P., N.R.-V.), Hospital Universitari Vall d'Hebron; Department of Neurology (L.S.), Hospital Universitari Joan XXIII, Tarragona; Hospital Universitari d'Igualada, Igualada (J.P.); Hospital de Figueres (X.C.), Figueres; Department of Neurology (J.Z.), Hospital Verge de la Cinta, Tortosa; Consorci Sanitari Alt Penedès-Garraf (E.C.), Vilafranca del Penedés; Xarxa Assistencial Universitària Manresa (N.M.C.), Manresa; Department of Neurology (J.K.), Hospital Universitari Mútua de Terrassa, Terrassa; Stroke Programme (S. Abilleira), Health Department of Catalonia, Barcelona; and Catalan Health Department (M.S.-P., O.F.), Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024; 403:2820-2836. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Xu X, Zhang H, Zhang J, Luo M, Wang Q, Zhao Y, Gan Z, Xu B, Chen X. Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial. BMC Med 2024; 22:244. [PMID: 38867192 PMCID: PMC11170771 DOI: 10.1186/s12916-024-03468-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy. METHODS In this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0-2 at the 6-month follow-up. RESULTS A total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000). CONCLUSIONS Compared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02811614.
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Affiliation(s)
- Xinghua Xu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
| | - Huaping Zhang
- Department of Neurosurgery, Jingzhou Central Hospital, Hubei, China
| | - Jiashu Zhang
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
| | - Ming Luo
- Department of Neurosurgery, Wuhan No.1 Hospital, Hubei, China
| | - Qun Wang
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yining Zhao
- Department of Neurosurgery, Erlangen-Nuernberg University Hospital, Erlangen, Germany
| | - Zhichao Gan
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Bainan Xu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xiaolei Chen
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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Luh HT, Zhu C, Kuo LT, Lo WL, Liu HW, Su YK, Su IC, Lin CM, Lai DM, Hsieh ST, Lin MC, Huang APH. Application of Robotic Stereotactic Assistance (ROSA) for spontaneous intracerebral hematoma aspiration and thrombolytic catheter placement. J Formos Med Assoc 2024:S0929-6646(24)00254-7. [PMID: 38866694 DOI: 10.1016/j.jfma.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes and results in 40% mortality at 30 days. Although conservative medical management is still the standard treatment for ICH patients with small hematoma, patients with residual hematoma ≤15 mL after surgery are associated with better functional outcomes and survival rates. This study reported our clinical experience with using Robotic Stereotactic Assistance (ROSA) as a safe and effective approach for stereotactic ICH aspiration and intra-clot catheter placement. METHODS A retrospective analysis was conducted of patients with spontaneous ICH who underwent ROSA-guided ICH aspiration surgery. ROSA-guided ICH surgical techniques, an aspiration and intra-clot catheter placement protocol, and a specific operative workflow (pre-operative protocol, intraoperative procedure and postoperative management) were employed to aspirate ICH using the ROSA One Brain, and appropriate follow-up care was provided. RESULTS From September 14, 2021 to May 4, 2022, a total of 7 patients were included in the study. Based on our workflow design, ROSA-guided stereotactic ICH aspiration effectively aspirated more than 50% of hematoma volume (or more than 30 mL for massive hematomas), thereby reducing the residual hematoma to less than 15 mL. The mean operative time of entire surgical procedure was 1.3 ± 0.3 h, with very little perioperative blood loss and no perioperative complications. No patients required catheter replacement and all patients' functional status improved. CONCLUSIONS Within our clinical practice ROSA-guided ICH aspiration, using our established protocol and workflow, was safe and effective for reducing hematoma volume, with positive functional outcomes.
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Affiliation(s)
- Hui-Tzung Luh
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chunran Zhu
- Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Wei-Lun Lo
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Heng-Wei Liu
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kai Su
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Min Lin
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Department of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Dar-Ming Lai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Chin Lin
- Taipei Neuroscience Institute, Taipei Medical University, New Taipei City, Taiwan; Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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9
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Seiffge DJ, Anderson CS. Treatment for intracerebral hemorrhage: Dawn of a new era. Int J Stroke 2024; 19:482-489. [PMID: 38803115 DOI: 10.1177/17474930241250259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Intracerebral hemorrhage (ICH) is a devastating disease, causing high rates of death, disability, and suffering across the world. For decades, its treatment has been shrouded by the lack of reliable evidence, and consequently, the presumption that an effective treatment is unlikely to be found. Neutral results arising from several major randomized controlled trials had established a negative spirit within and outside the stroke community. Frustration among researchers and a sense of nihilism in clinicians has created the general perception that patients presenting with ICH have a poor prognosis irrespective of them receiving any form of active management. All this changed in 2023 with the positive results on the primary outcome in randomized controlled trials showing treatment benefits for a hyperacute care bundle approach (INTERACT3), early minimal invasive hematoma evacuation (ENRICH), and use of factor Xa-inhibitor anticoagulation reversal with andexanet alfa (ANNEXa-I). These advances have now been extended in 2024 by confirmation that intensive blood pressure lowering initiated within the first few hours of the onset of symptoms can substantially improve outcome in ICH (INTERACT4) and that decompressive hemicraniectomy is a viable treatment strategy in patients with large deep ICH (SWITCH). This evidence will spearhead a change in the perception of ICH, to revolutionize the care of these patients to ultimately improve their outcomes. We review these and other recent developments in the hyperacute management of ICH. We summarize the results of randomized controlled trials and discuss related original research papers published in this issue of the International Journal of Stroke. These exciting advances demonstrate how we are now at the dawn of a new, exciting, and brighter era of ICH management.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Institute for Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China
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10
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Parry-Jones AR, Järhult SJ, Kreitzer N, Morotti A, Toni D, Seiffge D, Mendelow AD, Patel H, Brouwers HB, Klijn CJM, Steiner T, Gibler WB, Goldstein JN. Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement. Eur Stroke J 2024; 9:295-302. [PMID: 38149323 PMCID: PMC11318433 DOI: 10.1177/23969873231220235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023] Open
Abstract
PURPOSE Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. METHODS We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. FINDINGS In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. DISCUSSION There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.
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Affiliation(s)
- Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Susann J Järhult
- Department of Medical Sciences, Uppsala University, Emergency Department, Uppsala University Hospital, Uppsala, Sweden
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza Rome, Italy
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Hiren Patel
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Hens Bart Brouwers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Catharina JM Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Walter Brian Gibler
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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11
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Klijn CJ, Dammers R, Sprigg N. Decompressive craniectomy for deep intracerebral haemorrhage: a SWITCH towards better outcomes? Lancet 2024; 403:2351-2353. [PMID: 38761809 DOI: 10.1016/s0140-6736(24)00703-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/05/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Catharina Jm Klijn
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, 6525 GC Nijmegen, Netherlands.
| | - Ruben Dammers
- Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Nikola Sprigg
- Stroke Trials Unit Nottingham, University of Nottingham, Nottingham, UK
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12
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Woudstra K, Tummers M, Klijn CJM, Sondag L, Schreuder F, Reuzel R, Rovers M. Participatory methods used in the evaluation of medical devices: a comparison of focus groups, interviews, and a survey. BMC Health Serv Res 2024; 24:462. [PMID: 38609933 PMCID: PMC11015660 DOI: 10.1186/s12913-024-10887-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Stakeholder engagement in evaluation of medical devices is crucial for aligning devices with stakeholders' views, needs, and values. Methods for these engagements have however not been compared to analyse their relative merits for medical device evaluation. Therefore, we systematically compared these three methods in terms of themes, interaction, and time-investment. METHODS We compared focus groups, interviews, and an online survey in a case-study on minimally invasive endoscopy-guided surgery for patients with intracerebral haemorrhage. The focus groups and interviews featured two rounds, one explorative focussing on individual perspectives, and one interactive focussing on the exchange of perspectives between participants. The comparison between methods was made in terms of number and content of themes, how participants interact, and hours invested by all researchers. RESULTS The focus groups generated 34 themes, the interviews 58, and the survey 42. Various improvements for the assessment of the surgical procedure were only discussed in the interviews. In focus groups, participants were inclined to emphasise agreement and support, whereas the interviews consisted of questions and answers. The total time investment for researchers of focus groups was 95 h, of interviews 315 h, and survey 81 h. CONCLUSIONS Within the context of medical device evaluation, interviews appeared to be the most appropriate method for understanding stakeholder views since they provide a scope and depth of information that is not generated by other methods. Focus groups were useful to rapidly bring views together. Surveys enabled a quick exploration. Researchers should account for these methodological differences and select the method that is suitable for their research aim.
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Affiliation(s)
- Kas Woudstra
- Department of Health Evidence, Radboudumc, Nijmegen, Netherlands.
- Department of Operating Rooms, Radboudumc, Nijmegen, Netherlands.
| | - Marcia Tummers
- Department of Health Evidence, Radboudumc, Nijmegen, Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboudumc, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboudumc, Nijmegen, Netherlands
| | - Floris Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboudumc, Nijmegen, Netherlands
| | - Rob Reuzel
- Department of Health Evidence, Radboudumc, Nijmegen, Netherlands
| | - Maroeska Rovers
- Department of Operating Rooms, Radboudumc, Nijmegen, Netherlands
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13
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Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
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Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
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Pierini P, Novelli A, Bossi F, Corinaldesi R, Paciaroni M, Mosconi MG, Alberti A, Venti M, de Magistris IL, Caso V. Medical versus neurosurgical treatment in ICH patients: a single center experience. Neurol Sci 2024; 45:223-229. [PMID: 37578629 PMCID: PMC10761447 DOI: 10.1007/s10072-023-07015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND AND AIMS The effect of surgical treatment for spontaneous intracerebral hemorrhage (ICH) remains uncertain. We conducted an observational retrospective cohort study on supra-centimeter spontaneous ICH treated with either neurosurgical or conservative management. The baseline demographics and risk factors were correlated with in-hospital mortality and 3 and 6-month survival rates stratified by management. METHODS We included all patients with evidence of spontaneous ICH > 1 cm detected by CT and admitted between august 2020 and march 2021 to the "SMM" Hospital in Perugia. RESULTS Onehundredandtwentytwo patients were included in the study, and 45% (n.55) were surgically treated. The mean age was 71.9 ± 15.3, and 61% (n.75) were males. Intra-hospital mortality ended up being 31% (n.38), 3 months-survival was 63% (n.77) and 6 months-survival was 60% (n.73). From the multivariate analysis of the surgical patients versus medical patient, we observed that the surgical patients were younger (67.5 ± 14.9 vs 75.5 ± 14.7 y; OR 0.87; Cl 95% 0.85-0.94; p 0.001), with greater ICH volume at the onset (61 ± 39.4 cc vs 51 ± 64 cc; OR 1.03; Cl 95% 1.005-1.07; p 0.05), more midline shift (7.61 ± 5.54 mm vs 4.09 ± 5.88 mm; OR 1.37; Cl 95% 1.045-1.79; p 0.023), and a higher ICH score (3 vs 2 mean ICH score; OR 21.12; Cl 95% 2.6-170.6; p 0.004). Intra-hospital mortality in the surgical group and in the conservative treatment group was respectively 33% vs 30%, 3 month-survival was 64% vs 63% and 6 month- survival were 60% in both groups. CONCLUSIONS Our patient cohort shows no overall benefit from surgery over conservative treatment, but surgical patients were younger and had larger ICH volume.
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Affiliation(s)
- P Pierini
- Department of Emergency Medicine, Città Di Castello Hospital, Città Di Castello, Italy
| | - Agnese Novelli
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy.
| | - F Bossi
- Internal, Vascular and Emergency Medicine-Stroke Unit, Santa Maria della Misericordia University of Perugia, 06139, Perugia, Italy
| | - R Corinaldesi
- Neurosurgery Department, Santa Maria Della Misericordia Hospital, Perugia, Italy
| | - M Paciaroni
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M G Mosconi
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - A Alberti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - M Venti
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - I Leone de Magistris
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
| | - V Caso
- Stroke Unit, Santa Maria Della Misericordia, University of Perugia, Perugia, Italy
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15
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Kim S, Oh TK, Song IA, Jeon YT. Trend of Intensive Care Unit Admission in Neurology-Neurosurgery Adult Patients in South Korea : A Nationwide Population-Based Cohort Study. J Korean Neurosurg Soc 2024; 67:84-93. [PMID: 37558211 PMCID: PMC10788545 DOI: 10.3340/jkns.2023.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/25/2023] [Accepted: 08/05/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE We aimed to examine trends in critically ill neurology-neurosurgery (NNS) patients who were admitted to the intensive care unit (ICU) in South Korea and identify risk factors for in-hospital mortality after ICU admission in NNS patients. METHODS This nationwide population-based retrospective cohort study enrolled adult NNS adult patients admitted to the ICU from 2010 to 2019 extracted from the National Health Insurance Service in South Korea. The critically ill NNS patients were defined as those whose main admission departments were neurology or neurosurgery at ICU admission. The number of ICU admission, age, and total cost for hospitalization from 2010 to 2019 in critically ill NNS patients were examined as trend information. Moreover, multivariable logistic regression modeling was used to identify risk factors for in-hospital mortality among critically ill NNS patients. RESULTS We included 845474 ICU admission cases for 679376 critically ill NNS patients in South Korea between January 1, 2010 to December 31, 2019. The total number of ICU admissions among NNS patients was 79522 in 2010, which increased to 91502 in 2019. The mean age rose from 62.8 years (standard deviation [SD], 15.6) in 2010 to 66.6 years (SD, 15.2) in 2019, and the average total cost for hospitalization per each patient consistently increased from 6206.1 USD (SD, 5218.5) in 2010 to 10745.4 USD (SD, 10917.4) in 2019. In-hospital mortality occurred in 75455 patients (8.9%). Risk factors strongly associated with increased in-hospital mortality were the usage of mechanical ventilator (adjusted odds ratio [aOR], 19.83; 95% confidence interval [CI], 19.42-20.26; p<0.001), extracorporeal membrane oxygenation (aOR, 3.49; 95% CI, 2.42-5.02; p<0.001), and continuous renal replacement therapy (aOR, 6.47; 95% CI, 6.02-6.96; p<0.001). In addition, direct admission to ICU from the emergency room (aOR, 1.38; 95% CI, 1.36-1.41; p<0.001) and brain cancer as the main diagnosis (aOR, 1.30; 95% CI, 1.22-1.39; p<0.001) are also potential risk factors for increased in-hospital mortality. CONCLUSION In South Korea, the number of ICU admissions increased among critically ill NNS patients from 2010 to 2019. The average age and total costs for hospitalization also increased. Some potential risk factors are found to increase in-hospital mortality among critically ill NNS patients.
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Affiliation(s)
- Saeyeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
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16
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Ali M, Smith C, Vasan V, Downes M, Schuldt BR, Odland I, Murtaza-Ali M, Dullea J, Rossitto CP, Schupper AJ, Hardigan T, Asghar N, Liang J, Mocco J, Kellner CP. Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2023; 16:15-23. [PMID: 36882321 DOI: 10.1136/jnis-2023-020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly. OBJECTIVE To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation. METHODS Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively. RESULTS Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001). CONCLUSIONS We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Murtaza-Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Liu S, Su S, Long J, Cao S, Ren J, Li F, Wang S, Niu H, Gao Z, Gao H, Wang D, Hu F, Zhang X. The impact of time to evacuation on outcomes in endoscopic surgery for supratentorial spontaneous intracerebral hemorrhage: a single-center retrospective study. Neurosurg Rev 2023; 47:2. [PMID: 38057420 DOI: 10.1007/s10143-023-02237-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 12/08/2023]
Abstract
Supratentorial spontaneous intracerebral hemorrhage (SICH) can be treated with endoscopic surgery, but the optimal timing remains uncertain. We retrospectively analyzed data from 46 patients who underwent endoscopic surgery for supratentorial SICH. We examined the relationship between time to evacuation and functional outcome at 3 months, adjusting for prognostic factors. Surgical outcomes and complications were compared between patients with early (≤ 12 h) or late (> 12 h) evacuation. Median time to evacuation was 12 h, and the rate of unfavorable outcome (modified Rankin Scale > 3 at 3 months) was 32.6%. Longer time to evacuation was independently associated with unfavorable outcome (odds ratio per hour delay: 1.26). Late evacuation carried a 7.25-fold higher risk of unfavorable outcome compared to early evacuation. This association held across subgroups based on hematoma volume, location, and intraventricular extension (P for interaction > 0.05). Patients with late evacuation had fewer spot signs (24% vs. 4.8%, P = 0.035) and markers of hemorrhagic expansion (36% vs. 9.5%, P = 0.018), longer neurosurgical intensive care unit (NSICU) stay (3.2 vs. 1.9 days, P = 0.011) and hospital stay (15.7 vs. 11.9 days, P = 0.014), and higher 30-day mortality (28.6 vs. 4%, P = 0.036) and complication rates (57.1% vs. 28.0%, P = 0.023). This study suggests a potential association between early endoscopic evacuation of supratentorial SICH and improved functional outcomes, lower 30-day mortality and reduced complications. The need for timely intervention in managing supratentorial SICH is highlighted, yet further validation through multi-center prospective studies is essential to substantiate these findings and provide a higher level of evidence.
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Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shengyang Su
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jinyong Long
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shikui Cao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Jirao Ren
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fuhua Li
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Shoulong Wang
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
- Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Huatao Niu
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
- Department of Neurological Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China
| | - Zihui Gao
- Department of Surgery, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Huaxing Gao
- Department of Neurology, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Deqiang Wang
- Department of Critical Care Medicine, People's Hospital of Jinping Miao, Yao and Dai Autonomous Country, Honghe Prefecture, Yunnan Province, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Shentu HS, Chen YH, Cheng ZY, Fu B, Fu YH, Zheng SF, Li C. A Prospective Cohort Study of Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 as a Serologic Marker in Relation to Severity and Functional Outcome of Acute Intracerebral Hemorrhage. Neuropsychiatr Dis Treat 2023; 19:2363-2379. [PMID: 37954033 PMCID: PMC10637248 DOI: 10.2147/ndt.s433264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023] Open
Abstract
Background The inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) may regulate immunity and inflammation. The current study was conducted to determine its role as a biomarker for reflecting the severity and predicting outcomes of intracerebral hemorrhage (ICH). Methods In this prospective cohort study, 185 patients with supratentorial ICH were enrolled, among whom 62 had blood obtained not only at admission but also on days 1, 3, 5, 7, 10, and 14. In addition, 62 healthy controls underwent blood collection at the start of the study. The serum ITIH4 levels were then quantified. We recorded early neurological deterioration (END) and poor prognosis (modified Rankin Scale [mRS] scores of 3-6]) six months after ICH. Results Serum ITIH4 levels decreased prominently in the early phase after ICH, continued to decline until day 5, then gradually increased until day 14, and were significantly lower during 14 days in patients than in controls. Serum ITIH4 levels on admission were independently associated with serum C-reactive protein levels, National Institutes of Health Stroke Scale (NIHSS) scores and hematoma volume. Admission serum ITIH4 levels were independently associated with mRS scores, END, and poor prognosis. No substantial differences existed in the areas under the receiver operating characteristic curve of END and poor prognosis prediction between the serum ITIH4 levels, NIHSS scores, and hematoma volume. Prediction models, in which serum ITIH4 levels, NIHSS scores, and hematoma volume were integrated, were relatively reliable and stable using a series of statistical methods. In addition, the prediction model of poor prognosis had a higher discriminatory ability than the NIHSS scores and hematoma volume alone. Conclusion A dramatic decline in serum ITIH4 levels during the early period following ICH is independently related to the inflammatory response, stroke severity, and poor neurologic outcomes, suggesting that serum ITIH4 may be a useful prognostic biomarker of ICH.
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Affiliation(s)
- Hua-Song Shentu
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Yi-Hua Chen
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Zhen-Yu Cheng
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Bin Fu
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Yuan-Hao Fu
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Shu-Feng Zheng
- Department of Endocrinology, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
| | - Chan Li
- Department of Neurosurgery, Jinhua People’s Hospital, Affiliated Jinhua Hospital of Wenzhou Medical University, Jinhua, 321000, People’s Republic of China
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Eilertsen H, Menon CS, Law ZK, Chen C, Bath PM, Steiner T, Desborough MJ, Sandset EC, Sprigg N, Al-Shahi Salman R. Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 10:CD005951. [PMID: 37870112 PMCID: PMC10591281 DOI: 10.1002/14651858.cd005951.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Outcome after acute spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume. ICH expansion occurs in about 20% of people with acute ICH. Early haemostatic therapy might improve outcome by limiting ICH expansion. This is an update of a Cochrane Review first published in 2006, and last updated in 2018. OBJECTIVES To examine 1. the effects of individual classes of haemostatic therapies, compared with placebo or open control, in adults with acute spontaneous ICH, and 2. the effects of each class of haemostatic therapy according to the use and type of antithrombotic drug before ICH onset. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL (2022, Issue 8), MEDLINE Ovid, and Embase Ovid on 12 September 2022. To identify further published, ongoing, and unpublished randomised controlled trials (RCTs), we scanned bibliographies of relevant articles and searched international registers of RCTs in September 2022. SELECTION CRITERIA We included RCTs of any haemostatic intervention (i.e. procoagulant treatments such as clotting factor concentrates, antifibrinolytic drugs, platelet transfusion, or agents to reverse the action of antithrombotic drugs) for acute spontaneous ICH, compared with placebo, open control, or an active comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was death/dependence (modified Rankin Scale (mRS) 4 to 6) by day 90. Secondary outcomes were ICH expansion on brain imaging after 24 hours, all serious adverse events, thromboembolic adverse events, death from any cause, quality of life, mood, cognitive function, Barthel Index score, and death or dependence measured on the Extended Glasgow Outcome Scale by day 90. MAIN RESULTS We included 20 RCTs involving 4652 participants: nine RCTs of recombinant activated factor VII (rFVIIa) versus placebo/open control (1549 participants), eight RCTs of antifibrinolytic drugs versus placebo/open control (2866 participants), one RCT of platelet transfusion versus open control (190 participants), and two RCTs of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) (47 participants). Four (20%) RCTs were at low risk of bias in all criteria. For rFVIIa versus placebo/open control for spontaneous ICH with or without surgery there was little to no difference in death/dependence by day 90 (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.05; 7 RCTs, 1454 participants; low-certainty evidence). We found little to no difference in ICH expansion between groups (RR 0.81, 95% CI 0.56 to 1.16; 4 RCTs, 220 participants; low-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 0.81, 95% CI 0.30 to 2.22; 2 RCTs, 87 participants; very low-certainty evidence; death from any cause: RR 0.78, 95% CI 0.56 to 1.08; 8 RCTs, 1544 participants; moderate-certainty evidence). For antifibrinolytic drugs versus placebo/open control for spontaneous ICH, there was no difference in death/dependence by day 90 (RR 1.00, 95% CI 0.93 to 1.07; 5 RCTs, 2683 participants; high-certainty evidence). We found a slight reduction in ICH expansion with antifibrinolytic drugs for spontaneous ICH compared to placebo/open control (RR 0.86, 95% CI 0.76 to 0.96; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.02, 95% CI 0.75 to 1.39; 4 RCTs, 2599 participants; high-certainty evidence; death from any cause: RR 1.02, 95% CI 0.89 to 1.18; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in quality of life, mood, or cognitive function (quality of life: mean difference (MD) 0, 95% CI -0.03 to 0.03; 2 RCTs, 2349 participants; mood: MD 0.30, 95% CI -1.98 to 2.57; 2 RCTs, 2349 participants; cognitive function: MD -0.37, 95% CI -1.40 to 0.66; 1 RCTs, 2325 participants; all high-certainty evidence). Platelet transfusion likely increases death/dependence by day 90 compared to open control for antiplatelet-associated ICH (RR 1.29, 95% CI 1.04 to 1.61; 1 RCT, 190 participants; moderate-certainty evidence). We found little to no difference in ICH expansion between groups (RR 1.32, 95% CI 0.91 to 1.92; 1 RCT, 153 participants; moderate-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.46, 95% CI 0.98 to 2.16; 1 RCT, 190 participants; death from any cause: RR 1.42, 95% CI 0.88 to 2.28; 1 RCT, 190 participants; both moderate-certainty evidence). For PCC versus FFP for anticoagulant-associated ICH, the evidence was very uncertain about the effect on death/dependence by day 90, ICH expansion, all serious adverse events, and death from any cause between groups (death/dependence by day 90: RR 1.21, 95% CI 0.76 to 1.90; 1 RCT, 37 participants; ICH expansion: RR 0.54, 95% CI 0.23 to 1.22; 1 RCT, 36 participants; all serious adverse events: RR 0.27, 95% CI 0.02 to 3.74; 1 RCT, 5 participants; death from any cause: RR 0.49, 95% CI 0.16 to 1.56; 2 RCTs, 42 participants; all very low-certainty evidence). AUTHORS' CONCLUSIONS In this updated Cochrane Review including 20 RCTs involving 4652 participants, rFVIIa likely results in little to no difference in reducing death or dependence after spontaneous ICH with or without surgery; antifibrinolytic drugs result in little to no difference in reducing death or dependence after spontaneous ICH, but result in a slight reduction in ICH expansion within 24 hours; platelet transfusion likely increases death or dependence after antiplatelet-associated ICH; and the evidence is very uncertain about the effect of PCC compared to FFP on death or dependence after anticoagulant-associated ICH. Thirteen RCTs are ongoing and are likely to increase the certainty of the estimates of treatment effect.
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Affiliation(s)
- Helle Eilertsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Philip M Bath
- Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Thorsten Steiner
- Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Jr Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nikola Sprigg
- Stroke Medicine, University of Nottingham, Nottingham, UK
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Choi JH, Yoon WK, Kim JH, Kwon TH, Byun J. Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter. Korean J Neurotrauma 2023; 19:333-347. [PMID: 37840614 PMCID: PMC10567521 DOI: 10.13004/kjnt.2023.19.e41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023] Open
Abstract
Objective Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. Methods We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). Results The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. Conclusions The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.
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Affiliation(s)
- Jae Hoon Choi
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Won Ki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Taek Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus neurosurgical intensive care medicine : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:518-525. [PMID: 37195500 DOI: 10.1007/s00101-023-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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22
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Zhao H, Zhang T, Li M, Gao Y, Wang S, Jiang R, Li Z. Three-dimensional laser combined with C-arm computed tomography-assisted puncture of intracerebral hemorrhage. Front Endocrinol (Lausanne) 2023; 14:1198564. [PMID: 37448466 PMCID: PMC10338172 DOI: 10.3389/fendo.2023.1198564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/18/2023] [Indexed: 07/15/2023] Open
Abstract
Background Intracerebral hemorrhage (ICH) is the deadliest subtype of stroke, with a 30-day case fatality rate of approximately 40%. Timely and accurate treatment is essential to facilitate recovery. The introduction of stereotactic instruments and navigation systems has greatly improved the accuracy of surgical treatment. In this study, we explored the application and effects of a three-dimensional (3D) laser combined with C-arm computed tomography (CT) on ICH puncture. Materials and methods According to the principle of randomness, 118 patients with ICH were divided into control and experimental groups. The control group was treated with CT-guided puncture, and the experimental group was treated with 3D laser combined with C-arm CT puncture. The hematoma clearance rates at 3, 5, and 7 days after surgery and the prognosis at 1, 3, and 6 months after surgery were compared between the two groups. Results The hematoma clearance rates of the group using 3D laser combined with C-arm CT at 3, 5, and 7 days after surgery were significantly higher than those of the control group, and the difference was statistically significant (p < 0.05). One month postoperatively, the daily living ability (ADL) grading and recovery of the patients in the test group was significantly better than those of the control group (p < 0.05), but there was no statistically significant difference in ADL 3 and 6 months after surgery (p > 0.05). Conclusion 3D laser combined with C-arm CT puncture has the advantages of real-time guidance, accurate positioning, and simple operation. It is an effective minimally invasive surgical method that is easy to master.
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Affiliation(s)
- Hongwei Zhao
- Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Zhang
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Min Li
- Department of Ultrasound Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Yang Gao
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Shuangquan Wang
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Rongcai Jiang
- Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Zefu Li
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
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23
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Noiphithak R, Yindeedej V, Ratanavinitkul W, Duangprasert G, Nimmannitya P, Yodwisithsak P. Treatment outcomes between endoscopic surgery and conventional craniotomy for spontaneous supratentorial intracerebral hemorrhage: a randomized controlled trial. Neurosurg Rev 2023; 46:136. [PMID: 37278839 DOI: 10.1007/s10143-023-02035-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/24/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Minimally invasive surgery (MIS) has been repeatedly evaluated in patients with ICH as a promising procedure for improved survival and functional outcome. Among MIS techniques, endoscopic surgery (ES) has shown superior efficacy for ICH removal due to rapid clot evacuation and immediate bleeding control. However, the results of ES are still uncertain due to insufficient data. In this study, participants with spontaneous supratentorial ICH who were indicated for surgery were randomly assigned (1:1) to undergo ES or conventional craniotomy (CC) between March 2019 and June 2022. The primary outcome was a difference in favorable modified Rankin Scale (mRS) outcome (0 to 3) at 180-day follow-up evaluated by blind assessors. There were 188 participants, 95 in the ES group and 93 in the CC group, who completed the trial. At 180-day follow-up, 46 (48.4%) participants in the ES group achieved favorable outcomes, compared to 33 (35.5%) in the CC group (risk difference [RD] 12.9, 95% CI - 1.1-27.0, p = 0.07). After covariate adjustment, the difference was slightly higher and significant (adjusted RD 17.3, 95% CI [4.6-30.0], p = 0.01). Moreover, the ES group had less operative duration and less intraoperative blood loss than the CC group. Clot evacuation rate and complications were similar between the two groups. Subgroup analyses showed a potential benefit of ES in age < 60 years, time to surgery ≥ 6 h, and deep ICH. This study showed that ES was safe and effective in ICH removal and provided a better functional outcome compared to CC.
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Affiliation(s)
- Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Vich Yindeedej
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Pornchai Yodwisithsak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
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Hieber M, Lambeck J, Halaby A, Roelz R, Demerath T, Niesen WD, Bardutzky J. Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study. Front Neurol 2023; 14:1188717. [PMID: 37342780 PMCID: PMC10277509 DOI: 10.3389/fneur.2023.1188717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
Background and purpose The role of surgery in the treatment of intracerebral haemorrhage (ICH) remains controversial. Whereas open surgery has failed to show any clinical benefit, recent studies have suggested that minimal invasive procedures can indeed be beneficial, especially when they are applied at an early time point. This retrospective study therefore evaluated the feasibility of a free-hand bedside catheter technique with subsequent local lysis for early haematoma evacuation in patients with spontaneous supratentorial ICH. Methods Patients with spontaneous supratentorial haemorrhage of a volume of >30 mL who were treated with bedside catheter haematoma evacuation were identified from our institutional database. The entry point and evacuation trajectory of the catheter were based on a 3D-reconstructed CT scan. The catheter was inserted bedside into the core of the haematoma, and urokinase (5,000 IE) was administered every 6 h for a maximum of 4 days. Evolution of haematoma volume, perihaemorrhagic edema, midline-shift, adverse events and functional outcome were analyzed. Results A total of 110 patients with a median initial haematoma volume of 60.6 mL were analyzed. Haematoma volume decreased to 46.1 mL immediately after catheter placement and initial aspiration (with a median time to treatment of 9 h after ictus), and to 21.0 mL at the end of urokinase treatment. Perihaemorrhagic edema decreased significantly from 45.0 mL to 38.9 mL and midline-shift from 6.0 mm to 2.0 mm. The median NIHSS score improved from 18 on admission to 10 at discharge, and the median mRS at discharge was 4; the latter was even lower in patients who reached a target volume ≤ 15 mL at the end of local lysis. The in-hospital mortality rate was 8.2%, and catheter/local lysis-associated complications occurred in 5.5% of patients. Conclusion Bedside catheter aspiration with subsequent urokinase irrigation is a safe and feasible procedure for treating spontaneous supratentorial ICH, and can immediately reduce the mass effects of haemorrhage. Additional controlled studies that assess the long-term outcome and generalizability of our findings are therefore warranted. Clinical trial registration [www.drks.de], identifier [DRKS00007908].
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Affiliation(s)
- Maren Hieber
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amjad Halaby
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Zhang J, Liu C, Hu Y, Yang A, Zhang Y, Hong Y. The trend of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in spontaneous intracerebral hemorrhage and the predictive value of short-term postoperative prognosis in patients. Front Neurol 2023; 14:1189898. [PMID: 37305759 PMCID: PMC10248083 DOI: 10.3389/fneur.2023.1189898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/13/2023] Open
Abstract
Background Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) play an important role in the inflammatory response in various diseases, but the role in the course of spontaneous intracerebral hemorrhage (ICH) is unclear. Methods This study retrospectively collected baseline characteristics and laboratory findings, including NLR and PLR at different time points, from spontaneous ICH patients undergoing surgery between January 2016 and June 2021. Patients were scored using the modified Rankin Scale (mRS) to evaluate their functional status at 30 days post-operation. Patients with mRS score ≥3 were defined as poor functional status, and mRS score <3 was defined as good functional status. The NLR and PLR were calculated at admission, 48 h after surgery and 3-7 days after surgery, respectively, and their trends were observed by connecting the NLR and PLR at different time points. Multivariate logistic regression analysis was used to identify independent risk factors affecting the prognosis of ICH patients at 30 days after surgery. Results A total of 101 patients were included in this study, and 59 patients had a poor outcome at 30 days after surgery. NLR and PLR gradually increased and then decreased, peaking at 48 h after surgery. Univariate analysis demonstrated that admission Glasgow Coma Scale (GCS) score, interval from onset to admission, hematoma location, NLR within 48 h after surgery and PLR within 48 h after surgery were associated with poor 30-day prognosis. In multivariate logistic regression analysis, NLR within 48 h after surgery (OR, 1.147; 95% CI, 1.005, 1.308; P, 0.042) was an independent risk factor for 30-day after surgery prognosis in spontaneous ICH patients. Conclusion In the course of spontaneous intracerebral hemorrhage, NLR and PLR initially increased and subsequently decreased, reaching their peak values at 48 h after surgery. High NLR within 48 h after surgery was an independent risk factor for poor prognosis 30 days after surgery in spontaneous ICH patients.
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Affiliation(s)
- Jian Zhang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The Seventh Clinical College of China Medical University, Fushun, China
| | - Chunlong Liu
- Department of Hepatobiliary and Pancreatic Surgery, Fuyang People's Hospital, Anhui Medical University, Fuyang, China
| | - Yaofeng Hu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Aoran Yang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yonghui Zhang
- Department of Neurosurgery, The Seventh Clinical College of China Medical University, Fushun, China
| | - Yang Hong
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
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Gao L, Peng L, Sherchan P, Tang H, Liu Y, Xiao J, Shi H, Luo Y, Tang J, Zhang JH, Xia Y. Inhibition of lysophosphatidic acid receptor 1 relieves PMN recruitment in CNS via LPA1/TSP1/CXCR2 pathway and alleviates disruption on blood-brain barrier following intracerebral haemorrhage in mice. Fluids Barriers CNS 2023; 20:33. [PMID: 37165450 PMCID: PMC10173532 DOI: 10.1186/s12987-023-00434-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUD The frequencies of morbidity and impairment associated with spontaneous intracerebral haemorrhage (ICH) are comparatively high. Blood-brain barrier (BBB) integrity was compromised due to subsequent brain injury induced by ICH, which is crucial for a poor prognosis. Polymorphonuclear leukocyte (PMN) strongly modulate the disruption of BBB in the central nervous system (CNS). The lysophosphatidic acid receptor 1 (LPA1) mediated thrombospondin-1 (TSP1) regulation in astrocytes, which induce macrophage inflammatory protein 2(MIP2) secretion. MIP2 enhance PMN recruitment through CXC chemokine type 2 (CXCR2) activation. The purpose of this study was to investigate whether the LPA1-mediated inhibition of PMN recruitment and BBB protection after ICH is regulated by TSP1 and CXCR2 networks. METHODS ICH induction was performed in CD1 mice using collagenase administration. AM966, a targeted LPA1 antagonist, was orally administered 1 and 12 h following ICH. further identify possible LPA1-mediated BBB protection mechanisms, we intracerebroventricularly (ICV) administered a CXCR2 ligand MIP2, as well as TSP1 CRISPR activation (ACT) with AM966. Consequently, we performed neurobehavioral, brain water content (BWC), Evans blue staining (EBS), immunofluorescence (IF), and western blot (WB) analyses. RESULTS After ICH, astrocytes showed signs of LPA1, which peaked after 24 h, while PMN\ displayed evidence of CXCR2. The AM966-mediated LPA1 suppression relieved PMN recruitment, diminished brain oedema, demonstrated extravasation (as evidenced by EBS), protected BBB integrity, and enhanced neurologic activity following ICH. AM966 treatment strongly reduced TSP1, CXCR2, Occludin, and Claudin-5 expressions and PMN recruitment following ICH, and their expressions were restored by MIP2 and TSP1 CRISPR (ACT). CONCLUSIONS This study shows that LAP1 suppression reduced PMN recruitment after ICH in mice via TSP1/CXCR2 signalling, which minimized BBB disruption and improved the CNS's neurobehavioral functioning. Hence, LPA1 is a strong candidate for therapy to reduce PMN recruitment and offer protection of BBB integrity after ICH.
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Affiliation(s)
- Ling Gao
- Department of Neurosurgery, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, 570208, China
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Li Peng
- Department of Ophthalmology, Central South University Xiangya School of Medicine Affiliated Haikou Hospital, Haikou, Hainan, 570208, China
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, 410000, Hunan, China
| | - Prativa Sherchan
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Hong Tang
- Department of Neurosurgery, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, 570208, China
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Yu Liu
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Jie Xiao
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Hui Shi
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Yujie Luo
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - Jiping Tang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA
| | - John H Zhang
- Department of Physiology and Pharmacology, School of Medicine, Loma Linda University, Loma Linda, CA, 92354, USA.
- Department of Neurosurgery and Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, 92354, USA.
| | - Ying Xia
- Department of Neurosurgery, Affiliated Haikou Hospital, Xiangya School of Medicine, Central South University, Haikou, 570208, China.
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Almqvist T, Falk Delgado A, Sjöstrand C, Ahmed N, Berglund A, Eriksson E, Mazya MV. Impact of prehospital stroke triage implementation on patients with intracerebral hemorrhage. Ther Adv Neurol Disord 2023; 16:17562864231168278. [PMID: 37187462 PMCID: PMC10176564 DOI: 10.1177/17562864231168278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/18/2023] [Indexed: 05/17/2023] Open
Abstract
Background Little is known about how prehospital triage using large vessel occlusion (LVO) stroke prediction scales affects patients with intracerebral hemorrhage (ICH). Objectives We aimed to investigate whether the Stockholm Stroke Triage System (SSTS) implemented in 2017 has affected timing and outcomes of acute ICH neurosurgery, and to assess system triage accuracy for ICH with a neurosurgical indication or LVO thrombectomy. Design Observational cohort study. Methods In the Stockholm Region, we compared surgical timing, functional outcome, and death at 3 months in patients transported by code-stroke ground ambulance who had ICH neurosurgery, 2 years before versus 2 years after SSTS implementation. We also calculated triage precision metrics for treatment with either ICH neurosurgery or thrombectomy. Results A total of 36 patients undergoing ICH neurosurgery were included before SSTS implementation and 30 after. No significant difference was found in timing of neurosurgery [median 7.5 (4.9-20.7) versus 9.1 (6.1-12.5) h after onset], distribution of functional outcomes (median 4 versus 4), and death at 3 months [3/29 (9%) versus 5/35 (17%)] before versus after implementation, respectively. The SSTS routed a larger proportion of patients subsequently undergoing ICH neurosurgery directly to the comprehensive stroke center: 13/36 (36%) before versus 18/30 (60%) after implementation. Overall system triage accuracy for ICH neurosurgery or thrombectomy was high at 90%, with 92% specificity and 65% sensitivity. Conclusion The SSTS, initially designed for prehospital LVO stroke triage, routed more patients with neurosurgical indication for ICH directly to the comprehensive stroke center. This did not significantly affect surgical timing or outcomes.
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Affiliation(s)
- Tove Almqvist
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, 171 64 Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neuroradiology, Karolinska
University Hospital, University Hospital
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Neurology, Danderyd Hospital,
Stockholm, Sweden
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Annika Berglund
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Einar Eriksson
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
| | - Michael V. Mazya
- Department of Clinical Neuroscience,
Karolinska Institutet, Karolinska University Hospital, Stockholm,
Sweden
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
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Scholte M, Marchau VAWJ, Kwakkel JH, Klijn CJM, Rovers MM, Grutters JPC. Dealing With Uncertainty in Early Health Technology Assessment: An Exploration of Methods for Decision Making Under Deep Uncertainty. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:694-703. [PMID: 36253242 DOI: 10.1016/j.jval.2022.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES In early stages, the consequences of innovations are often unknown or deeply uncertain, which complicates early health economic modeling (EHEM). The field of decision making under deep uncertainty uses exploratory modeling (EM) in situations when the system model, input probabilities/distributions, and consequences are unknown or debated. Our aim was to evaluate the use of EM for early evaluation of health technologies. METHODS We applied EM and EHEM to an early evaluation of minimally invasive endoscopy-guided surgery (MIS) for acute intracerebral hemorrhage and compared these models to derive differences, merits, and drawbacks of EM. RESULTS EHEM and EM differ fundamentally in how uncertainty is handled. Where in EHEM the focus is on the value of technology, while accounting for the uncertainty, EM focuses on the uncertainty. EM aims to find robust strategies, which give relatively good outcomes over a wide range of plausible futures. This was reflected in our case study. EHEM provided cost-effectiveness thresholds for MIS effectiveness, assuming fixed MIS costs. EM showed that a policy with a population in which most patients had severe intracerebral hemorrhage was most robust, regardless of MIS effectiveness, complications, and costs. CONCLUSIONS EHEM and EM were found to complement each other. EM seems most suited in the very early phases of innovation to explore existing uncertainty and many potential strategies. EHEM seems most useful to optimize promising strategies, yet EM methods are complex and might only add value when stakeholders are willing to consider multiple solutions to a problem and adopt flexible research and adoption strategies.
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Affiliation(s)
- Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Jan H Kwakkel
- Faculty of Technology, Policy and Management, Delft, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Sondag L, Schreuder FHBM, Pegge SAH, Coutinho JM, Dippel DWJ, Janssen PM, Vandertop WP, Boogaarts HD, Dammers R, Klijn CJM. Safety and technical efficacy of early minimally invasive endoscopy-guided surgery for intracerebral haemorrhage: the Dutch Intracerebral haemorrhage Surgery Trial pilot study. Acta Neurochir (Wien) 2023; 165:1585-1596. [PMID: 37103585 PMCID: PMC10134719 DOI: 10.1007/s00701-023-05599-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Previous randomised controlled trials could not demonstrate that surgical evacuation of intracerebral haemorrhage (ICH) improves functional outcome. Increasing evidence suggests that minimally invasive surgery may be beneficial, in particular when performed early after symptom onset. The aim of this study was to investigate safety and technical efficacy of early minimally invasive endoscopy-guided surgery in patients with spontaneous supratentorial ICH. METHODS The Dutch Intracerebral Haemorrhage Surgery Trial pilot study was a prospective intervention study with blinded outcome assessment in three neurosurgical centres in the Netherlands. We included adult patients with spontaneous supratentorial ICH ≥10mL and National Institute of Health Stroke Scale (NIHSS) score ≥2 for minimally invasive endoscopy-guided surgery within 8 h after symptom onset in addition to medical management. Primary safety outcome was death or increase in NIHSS ≥4 points at 24 h. Secondary safety outcomes were procedure-related serious adverse events (SAEs) within 7 days and death within 30 days. Primary technical efficacy outcome was ICH volume reduction (%) at 24 h. RESULTS We included 40 patients (median age 61 years; IQR 51-67; 28 men). Median baseline NIHSS was 19.5 (IQR 13.3-22.0) and median ICH volume 47.7mL (IQR 29.4-72.0). Six patients had a primary safety outcome, of whom two already deteriorated before surgery and one died within 24 h. Sixteen other SAEs were reported within 7 days in 11 patients (of whom two patients that already had a primary safety outcome), none device related. In total, four (10%) patients died within 30 days. Median ICH volume reduction at 24 h was 78% (IQR 50-89) and median postoperative ICH volume 10.5mL (IQR 5.1-23.8). CONCLUSIONS Minimally invasive endoscopy-guided surgery within 8 h after symptom onset for supratentorial ICH appears to be safe and can effectively reduce ICH volume. Randomised controlled trials are needed to determine whether this intervention also improves functional outcome. TRIAL REGISTRATION Clinicaltrials.gov : NCT03608423, August 1st, 2018.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands
| | - Sjoert A H Pegge
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paula M Janssen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Neurosurgery, Amsterdam Neurosciences, Neurovascular Disorders, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, PO-box 9101, 6500HB, Nijmegen, The Netherlands.
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Hemorrhagic Stroke in Pregnancy. Clin Obstet Gynecol 2023; 66:223-230. [PMID: 36044629 DOI: 10.1097/grf.0000000000000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hemorrhagic stroke carries a high risk of disability and mortality. The obstetrical population is at increased risk. Prompt diagnosis and maternal stabilization with a multidisciplinary approach are the mainstays in management. Computed tomography head is the diagnostic imaging of choice and is considered safe in pregnancy. Fetal status optimization before neurosurgery and delivery should be considered if the fetus is viable or if worsening maternal condition. Obstetric indications guide the mode of delivery. Cesarean delivery may be indicated to reduce increasing intracranial pressure. Neuraxial anesthesia should be considered to minimize catecholamine surges, reduce sedation, and control blood pressures.
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Weimar C, Thomalla G, Sandalcioglu IE. [Intracerebral Hemorrhage]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2023; 91:104-119. [PMID: 36917974 DOI: 10.1055/a-2000-3783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Intracerebral hemorrhage (ICB) causes approximately 12% of all strokes in Germany and 9-27% of all strokes worldwide 1 2. Epidemiological studies show a decrease in younger individuals mainly due to better antihypertensive management, but there is also an increase in incidence in older individuals due to cerebral amyloid angiopathy and increasing use of anticoagulants 3.
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Fang Y, Wang J, Chen L, Yan W, Gao S, Liu Y, Wang X, Dong X, Zhang J, Chen S, Liu F, Wang Z, Zhang Y. Functional Outcome Analysis of Stereotactic Catheter Aspiration for Spontaneous Intracerebral Hemorrhage: Early or Late Hematoma Evacuation? J Clin Med 2023; 12:jcm12041533. [PMID: 36836067 PMCID: PMC9962962 DOI: 10.3390/jcm12041533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Minimally invasive stereotactic catheter aspiration becoming a promising surgical alternative for intracerebral hemorrhage (ICH) patients. Our goal is to determine the risk factors that lead to poor functional outcomes in patients undergoing this procedure. METHODS Clinical data of 101 patients with stereotactic catheter ICH aspiration were retrospectively reviewed. Univariate and multiple logistic analyses were used to identify risk factors for poor outcomes 3 months and 1 year after discharge. Univariate analysis was used to compare the functional outcome between early (<48 h after ICH onset) and late hematoma evacuation (≥48 h after ICH onset) groups, as well as for the odd ratios assessment in terms of rebleeding. RESULTS Independent factors for poor 3-month outcome included lobar ICH, ICH score > 2, rebleeding, and delayed hematoma evacuation. Factors for poor 1-year outcome included age > 60, GCS < 13, lobar ICH, and rebleeding. Early hematoma evacuation was linked to a lower likelihood of poor outcome both 3 months and 1 year post-discharge, but with higher risk of postoperative rebleeding. CONCLUSIONS Lobar ICH and rebleeding independently predicted both poor short- and long-term outcomes in patients with stereotactic catheter ICH evacuation. Early hematoma evacuation with preoperative rebleeding risk evaluation may benefit patients with stereotactic catheter ICH evacuation.
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Affiliation(s)
- Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
- Correspondence: (Y.F.); (Z.W.); (Y.Z.); Tel.: +86-571-87784719 (Y.F. & Y.Z.); +86-571-87784715 (Z.W.); Fax: +86-571-87784755 (Y.F. & Z.W. & Y.Z.)
| | - Junjie Wang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Department of Neurosurgery, The Fourth Affiliated Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Yiwu 310030, China
| | - Luxi Chen
- Department of Medical Genetics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Department of Neurology, Research Center of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wei Yan
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Shiqi Gao
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Xiao Dong
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Fengqiang Liu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
| | - Zefeng Wang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
- Correspondence: (Y.F.); (Z.W.); (Y.Z.); Tel.: +86-571-87784719 (Y.F. & Y.Z.); +86-571-87784715 (Z.W.); Fax: +86-571-87784755 (Y.F. & Z.W. & Y.Z.)
| | - Yang Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou 310009, China
- Correspondence: (Y.F.); (Z.W.); (Y.Z.); Tel.: +86-571-87784719 (Y.F. & Y.Z.); +86-571-87784715 (Z.W.); Fax: +86-571-87784755 (Y.F. & Z.W. & Y.Z.)
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Jakobsson J, Redebrandt HN, Tobieson L, Bartek J, Bartley A, Troberg E, Mirza S, Tsitsopoulos PP, Marklund N, Fahlström A. Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort. World Neurosurg 2023; 170:e351-e363. [PMID: 36368454 DOI: 10.1016/j.wneu.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation. METHODS A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed. RESULTS The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality. CONCLUSIONS Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.
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Affiliation(s)
- Johan Jakobsson
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Henrietta Nittby Redebrandt
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Lovisa Tobieson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jiri Bartek
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Bartley
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ebba Troberg
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Sadia Mirza
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neurosurgery, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Andreas Fahlström
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Australia.
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34
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Ali M, Zhang X, Ascanio LC, Troiani Z, Smith C, Dangayach NS, Liang JW, Selim M, Mocco J, Kellner CP. Long-term functional independence after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurosurg 2023; 138:154-164. [PMID: 35561694 DOI: 10.3171/2022.3.jns22286] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/31/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Intracerebral hemorrhage (ICH) is a devastating form of stroke with no proven treatment. However, minimally invasive endoscopic evacuation is a promising potential therapeutic option for ICH. Herein, the authors examine factors associated with long-term functional independence (modified Rankin Scale [mRS] score ≤ 2) in patients with spontaneous ICH who underwent minimally invasive endoscopic evacuation. METHODS Patients with spontaneous supratentorial ICH who had presented to a large urban healthcare system from December 2015 to October 2018 were triaged to a central hospital for minimally invasive endoscopic evacuation. Inclusion criteria for this study included age ≥ 18 years, hematoma volume ≥ 15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, premorbid mRS score ≤ 3, and time from ictus ≤ 72 hours. Demographic, clinical, and radiographic factors previously shown to impact functional outcome in ICH were included in a retrospective univariate analysis with patients dichotomized into independent (mRS score ≤ 2) and dependent (mRS score ≥ 3) outcome groups, according to 6-month mRS scores. Factors that reached a threshold of p < 0.05 in a univariate analysis were included in a multivariate logistic regression. RESULTS A total of 90 patients met the study inclusion criteria. The median preoperative hematoma volume was 41 (IQR 27-65) ml and the median postoperative volume was 1.2 (0.3-7.5) ml, resulting in a median evacuation percentage of 97% (85%-99%). The median hospital length of stay was 17 (IQR 9-25) days, and 8 (9%) patients died within 30 days of surgery. Twenty-four (27%) patients had attained functional independence by 6 months. Factors independently associated with long-term functional independence included lower NIHSS score at presentation (OR per point 0.78, 95% CI 0.67-0.91, p = 0.002), lack of intraventricular hemorrhage (IVH; OR 0.20, 95% CI 0.05-0.77, p = 0.02), and shorter time to evacuation (OR per hour 0.95, 95% CI 0.91-0.99, p = 0.007). Specifically, patients who had undergone evacuation within 24 hours of ictus demonstrated an mRS score ≤ 2 rate of 36% and were associated with an increased likelihood of long-term independence (OR 17.7, 95% CI 1.90-164, p = 0.01) as compared to those who had undergone evacuation after 48 hours. CONCLUSIONS In a single-center minimally invasive endoscopic ICH evacuation cohort, NIHSS score on presentation, lack of IVH, and shorter time to evacuation were independently associated with functional independence at 6 months. Factors associated with functional independence may help to better predict populations suitable for minimally invasive endoscopic evacuation and guide protocols for future clinical trials.
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Affiliation(s)
- Muhammad Ali
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Xiangnan Zhang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Luis C Ascanio
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Zachary Troiani
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Colton Smith
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Neha S Dangayach
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - John W Liang
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Magdy Selim
- 2Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - J Mocco
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Christopher P Kellner
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
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35
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Hallenberger TJ, Guzman R, Bonati LH, Greuter L, Soleman J. Endoscopic surgery for spontaneous supratentorial intracerebral haemorrhage: A systematic review and meta-analysis. Front Neurol 2022; 13:1054106. [PMID: 36605784 PMCID: PMC9807598 DOI: 10.3389/fneur.2022.1054106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Treatment for spontaneous supratentorial intracerebral haemorrhage (SSICH) is limited and consist of either best medical treatment (BMT) or surgical hematoma evacuation. Treatment methods and choice of surgical technique are debated, and so far, no clear advantage of endoscopic surgery (ES) over conventional craniotomy (CC) or BMT was shown. The aim of this systematic review and meta-analysis was to investigate the differences in outcome, morbidity, and mortality between ES and CC or BMT. Methods We systematically searched Embase and PubMed databases for randomised controlled trials comparing ES to CC or BMT. The primary outcome was favourable functional outcome after 6 months. Secondary outcomes were morbidity and mortality rates and duration of surgery. Results Seven articles were eligible for the outcome analysis with 312 subjects in the control (216 CC, 96 BMT) and 279 in the treatment group (ES). Compared to BMT, ES showed significantly improved favourable functional outcome (RR 1.93 [1.12; 3.33], p = 0.02) and mortality rates (RR 0.63 [0.44; 0.90], p = 0.01). No significant difference in favourable functional outcome and mortality was seen in ES compared to CC (RR 2.13 [0.01; 737], p = 0.35; RR 0.42 [0.17; 1.05], p = 0.06). ES showed significantly lower morbidity (RR 0.41 [0.29; 0.58], p < 0.01), and overall infection rates (RR 0.33 [0.20; 0.54], p < 0.01) compared to CC. Duration of surgery was significantly shorter for ES compared to CC (SMD -3.17 [-4.35; -2.00], p < 0.01). Conclusion ES showed significantly improved favourable functional outcome and mortality rates compared to BMT while showing reduced length of surgery and lower complication rates compared to CC. Therefore, ES appears a promising approach for treatment of SSICH justifying further prospective trials. Systematic review registration PROSPERO, identifier: CRD42020181018.
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Affiliation(s)
- Tim J. Hallenberger
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland,Faculty of Medicine, University of Basel, Basel, Switzerland,Division of Paediatric Neurosurgery, Children's University Hospital of Basel, Basel, Switzerland
| | - Leo H. Bonati
- Faculty of Medicine, University of Basel, Basel, Switzerland,Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland,Faculty of Medicine, University of Basel, Basel, Switzerland,Division of Paediatric Neurosurgery, Children's University Hospital of Basel, Basel, Switzerland,*Correspondence: Jehuda Soleman ✉
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36
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Wilting FNH, Sondag L, Schreuder FHBM, Vinke RS, Dammers R, Klijn CJM, Boogaarts HD. Surgery for spontaneous supratentorial intracerebral haemorrhage. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022; 2022:CD015387. [PMCID: PMC9743082 DOI: 10.1002/14651858.cd015387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique.
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Affiliation(s)
| | - Floor NH Wilting
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - Floris HBM Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
| | - R Saman Vinke
- Department of NeurosurgeryRadboud University Medical CentreNijmegenNetherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical CentreErasmus MC Stroke CentreRotterdamNetherlands
| | - Catharina JM Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and BehaviourRadboud University Medical CentreNijmegenNetherlands
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Activation of Nrf2 to Optimise Immune Responses to Intracerebral Haemorrhage. Biomolecules 2022; 12:biom12101438. [PMID: 36291647 PMCID: PMC9599325 DOI: 10.3390/biom12101438] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022] Open
Abstract
Haemorrhage into the brain parenchyma can be devastating. This manifests as spontaneous intracerebral haemorrhage (ICH) after head trauma, and in the context of vascular dementia. Randomised controlled trials have not reliably shown that haemostatic treatments aimed at limiting ICH haematoma expansion and surgical approaches to reducing haematoma volume are effective. Consequently, treatments to modulate the pathophysiological responses to ICH, which may cause secondary brain injury, are appealing. Following ICH, microglia and monocyte derived cells are recruited to the peri-haematomal environment where they phagocytose haematoma breakdown products and secrete inflammatory cytokines, which may trigger both protective and harmful responses. The transcription factor Nrf2, is activated by oxidative stress, is highly expressed by central nervous system microglia and macroglia. When active, Nrf2 induces a transcriptional programme characterised by increased expression of antioxidant, haem and heavy metal detoxification and proteostasis genes, as well as suppression of proinflammatory factors. Therefore, Nrf2 activation may facilitate adaptive-protective immune cell responses to ICH by boosting resistance to oxidative stress and heavy metal toxicity, whilst limiting harmful inflammatory signalling, which can contribute to further blood brain barrier dysfunction and cerebral oedema. In this review, we consider the responses of immune cells to ICH and how these might be modulated by Nrf2 activation. Finally, we propose potential therapeutic strategies to harness Nrf2 to improve the outcomes of patients with ICH.
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38
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Luo Q, Luan X, Xia C, Hou L, Wang Q, Zhao M, Tang H, Zheng H, He H, Xiang W, Wang J, Zhou J. Effects of nursing support workers participation on negative emotions, quality of life and life satisfaction of patients with cerebral hemorrhage: a quasi-experimental study. BMC Nurs 2022; 21:256. [PMID: 36123689 PMCID: PMC9484053 DOI: 10.1186/s12912-022-01040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to the high nursing pressure of patients with cerebral hemorrhage and the general shortage of clinical nurses, nursing support workers often participate in clinical nursing work, but the influence of nursing support workers' participation on the negative emotion, quality of life and life satisfaction of patients with intracerebral hemorrhage is unknown. METHODS This quasi-experimental study was conducted with a pretest-posttest design. A total of 181 ICH patients admitted to our hospital from January 2022 to April 2022 were enrolled, including 81 patients receiving conventional care (CG control group) and 80 patients receiving nursing support worker participation (RG research group). All patients were recorded with self-perceived Burden Scale (SPBS), Hamilton Depression Scale (HAMD), Quality of Life Scale (SF-36), Somatic Self rating Scale (SSS), Patient self-care ability assessment scale (Barthel) and Satisfaction with life scale (SWLS) scores. RESULTS Patients with high negative emotion were more willing to participate in clinical nursing work (p < 0.05). Nursing support workers involved in cerebral hemorrhage patients can alleviate negative emotions, improve life quality, improve life satisfaction (p < 0.05). CONCLUSION The participation of nursing support workers can alleviate the negative emotions of ICH patients, enhance their self-management ability, and improve their life quality.
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Affiliation(s)
- Qinglian Luo
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China.,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China
| | - Xingzhao Luan
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Southwest Medical University, Luzhou, 646000, China
| | - Chengling Xia
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China.,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China
| | - Liming Hou
- Department of Neurosurgery, Hejiang County People's Hospital, Sichuan Province, Luzhou, 646000, China
| | - Qisheng Wang
- Department of Neurosurgery, Hejiang County People's Hospital, Sichuan Province, Luzhou, 646000, China
| | - Mingkuan Zhao
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Southwest Medical University, Luzhou, 646000, China
| | - Hua Tang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Southwest Medical University, Luzhou, 646000, China
| | - Haowen Zheng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China.,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China
| | - Haiping He
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China.,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China
| | - Wei Xiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China.,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China
| | - Jianmei Wang
- Department of Pathology, Affiliated Hospital of Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China.
| | - Jie Zhou
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Southwest Medical University, Taiping Street 25#, Luzhou, 646000, Sichuan Province, China. .,Sichuan Clinical Research Center for Neurosurgery, Luzhou, 646000, China. .,Academician (Expert) Workstation of Sichuan Province, Luzhou, 646000, China.
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Demerath T, Stanicki A, Roelz R, Farina Nunez MT, Bissolo M, Steiert C, Fistouris P, Coenen VA, Urbach H, Fung C, Beck J, Reinacher PC. Accuracy of augmented reality-guided drainage versus stereotactic and conventional puncture in an intracerebral hemorrhage phantom model. J Neurointerv Surg 2022:neurintsurg-2022-018678. [PMID: 35853700 DOI: 10.1136/neurintsurg-2022-018678] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Minimally invasive intracranial drain placement is a common neurosurgical emergency procedure in patients with intracerebral hemorrhage (ICH). We aimed to retrospectively investigate the accuracy of conventional freehand (bedside) hemorrhage drain placement and to prospectively compare the accuracy of augmented/mixed reality-guided (AR) versus frame-based stereotaxy-guided (STX) and freehand drain placement in a phantom model. METHODS A retrospective, single-center analysis evaluated the accuracy of drain placement in 73 consecutive ICH with a visual rating of postinterventional CT data. In a head phantom with a simulated deep ICH, five neurosurgeons performed four punctures for each technique: STX, AR, and the freehand technique. The Euclidean distance to the target point and the lateral deviation of the achieved trajectory from the planned trajectory at target point level were compared between the three methods. RESULTS Analysis of the clinical cases revealed an optimal drainage position in only 46/73 (63%). Correction of the drain was necessary in 23/73 cases (32%). In the phantom study, accuracy of AR was significantly higher than the freehand method (P<0.001 for both Euclidean and lateral distances). The Euclidean distance using AR (median 3 mm) was close to that using STX (median 1.95 mm; P=0.023). CONCLUSIONS We demonstrated that the accuracy of the freehand technique was low and that subsequent position correction was common. In a phantom model, AR drainage placement was significantly more precise than the freehand method. AR has great potential to increase precision of emergency intracranial punctures in a bedside setting.
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Affiliation(s)
- Theo Demerath
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amin Stanicki
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mateo Tomas Farina Nunez
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Bissolo
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Steiert
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Panagiotis Fistouris
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker Arnd Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Christoph Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany .,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
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40
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Schreuder FHBM, Scholte M, Ulehake MJ, Sondag L, Rovers MM, Dammers R, Klijn CJM, Grutters JPC. Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage. Front Neurol 2022; 13:830614. [PMID: 35720058 PMCID: PMC9200972 DOI: 10.3389/fneur.2022.830614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.
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Affiliation(s)
- Floris H. B. M. Schreuder
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marike J. Ulehake
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Janneke P. C. Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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41
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 404] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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42
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Advancing the Surgical Treatment of Intracerebral Hemorrhage: Study Design and Research Directions. World Neurosurg 2022; 161:367-375. [DOI: 10.1016/j.wneu.2022.01.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 12/23/2022]
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43
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Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng 2022; 50:365-386. [PMID: 35226279 DOI: 10.1007/s10439-022-02934-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/11/2022] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.
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Affiliation(s)
- Mishek J Musa
- Department of Mechanical Engineering, University of Arkansas, Fayetteville, AR, USA
| | | | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, NY, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, The George Washington University, Washington, Washington, DC, USA
| | - Isuru Godage
- College of Computing and Digital Media, DePaul University, Chicago, IL, USA
| | - Saikat Sengupta
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chima Oluigbo
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
| | - Yue Chen
- Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Dr NW, Atlanta, GA, 30332, USA.
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44
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Falcone J, Chen JW. Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:123-130. [PMID: 35030111 DOI: 10.1227/ons.0000000000000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques. OBJECTIVE To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA. METHODS Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival. RESULTS Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion. CONCLUSION Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.
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Affiliation(s)
- Joseph Falcone
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
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45
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Wang H, Tang J, Wu M, Wang X, Zhang T. Application of machine learning missing data imputation techniques in clinical decision making: taking the discharge assessment of patients with spontaneous supratentorial intracerebral hemorrhage as an example. BMC Med Inform Decis Mak 2022; 22:13. [PMID: 35027065 PMCID: PMC8756624 DOI: 10.1186/s12911-022-01752-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background There are often many missing values in medical data, which directly affect the accuracy of clinical decision making. Discharge assessment is an important part of clinical decision making. Taking the discharge assessment of patients with spontaneous supratentorial intracerebral hemorrhage as an example, this study adopted the missing data processing evaluation criteria more suitable for clinical decision making, aiming at systematically exploring the performance and applicability of single machine learning algorithms and ensemble learning (EL) under different data missing scenarios, as well as whether they had more advantages than traditional methods, so as to provide basis and reference for the selection of suitable missing data processing method in practical clinical decision making. Methods The whole process consisted of four main steps: (1) Based on the original complete data set, missing data was generated by simulation under different missing scenarios (missing mechanisms, missing proportions and ratios of missing proportions of each group). (2) Machine learning and traditional methods (eight methods in total) were applied to impute missing values. (3) The performances of imputation techniques were evaluated and compared by estimating the sensitivity, AUC and Kappa values of prediction models. (4) Statistical tests were used to evaluate whether the observed performance differences were statistically significant. Results The performances of missing data processing methods were different to a certain extent in different missing scenarios. On the whole, machine learning had better imputation performance than traditional methods, especially in scenarios with high missing proportions. Compared with single machine learning algorithms, the performance of EL was more prominent, followed by neural networks. Meanwhile, EL was most suitable for missing imputation under MAR (the ratio of missing proportion 2:1) mechanism, and its average sensitivity, AUC and Kappa values reached 0.908, 0.924 and 0.596 respectively. Conclusions In clinical decision making, the characteristics of missing data should be actively explored before formulating missing data processing strategies. The outstanding imputation performance of machine learning methods, especially EL, shed light on the development of missing data processing technology, and provided methodological support for clinical decision making in presence of incomplete data.
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46
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Anderson CS. Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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47
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Barros G, Nistal D, Martini ML, Kellner CP, Levitt MR. Bilateral Endoscopic Intracerebral Hemorrhage Evacuations at Two Separate Time Points: A Case Report. Cureus 2021; 13:e20613. [PMID: 35103189 PMCID: PMC8782261 DOI: 10.7759/cureus.20613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
In this case report, we describe bilateral endoscopic intracerebral hemorrhage (ICH) evacuations in patients presenting on temporally distinct occasions with separate, contralateral lesions. Two patients presented with spontaneous right-sided ICH and underwent endoscopic evacuations. Both patients achieved some degree of functional improvement postoperatively. Each patient then experienced a second ICH in the left hemisphere months later, and again underwent endoscopic evacuation of the contralateral lesion. Postoperatively, both patients faced significantly longer hospitalizations and severe drops in functional independence compared to the first surgery. Functional outcomes after contralateral endoscopic ICH evacuation may vary significantly, and bilateral disease portends a worse prognosis.
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48
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Tobieson L, Gard A, Ruscher K, Marklund N. Intracerebral Proinflammatory Cytokine Increase in Surgically Evacuated Intracerebral Hemorrhage: A Microdialysis Study. Neurocrit Care 2021; 36:876-887. [PMID: 34850333 PMCID: PMC9110446 DOI: 10.1007/s12028-021-01389-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
Background Treatment options for spontaneous intracerebral hemorrhage (ICH) are limited. A possible inflammatory response in the brain tissue surrounding an ICH may exacerbate the initial injury and could be a target for treatment of subsequent secondary brain injury. The study objective was to compare levels of inflammatory mediators in the interstitial fluid of the perihemorrhagic zone (PHZ) and in seemingly normal cortex (SNX) in the acute phase after surgical evacuation of ICH, with the hypothesis being that a difference could be demonstrated between the PHZ and the SNX. Methods In this observational study, ten patients needing surgical evacuation of supratentorial ICH received two cerebral microdialysis catheters: one in the PHZ and one in the SNX that is remote from the ICH. The microdialysate was analyzed for energy metabolites (including lactate pyruvate ratio and glucose) and for inflammatory mediators by using a multiplex immunoassay of 27 cytokines and chemokines at 6–10 h, 20–26 h, and 44–50 h after surgery.
Results A metabolic crisis, indicated by altered energy metabolic markers, that persisted throughout the observation period was observed in the PHZ when compared with the SNX. Proinflammatory cytokines interleukin (IL) 8, tumor necrosis factor α, IL-2, IL-1β, IL-6 and interferon γ, anti-inflammatory cytokine IL-13, IL-4, and vascular endothelial growth factor A were significantly higher in PHZ compared with SNX and were most prominent at 20–26 h following ICH evacuation.
Conclusions Higher levels of both proinflammatory and anti-inflammatory cytokines in the perihemorrhagic brain tissue implies a complex role for inflammatory mediators in the secondary injury cascades following ICH surgery, suggesting a need for targeted pharmacological interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01389-9.
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Affiliation(s)
- Lovisa Tobieson
- Departments of Neurosurgery in Linköping and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Anna Gard
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Karsten Ruscher
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden.,Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hopsital, Lund, Sweden
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49
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Kellner CP, Song R, Ali M, Nistal DA, Samarage M, Dangayach NS, Liang J, McNeill I, Zhang X, Bederson JB, Mocco J. Time to Evacuation and Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation. Stroke 2021; 52:e536-e539. [PMID: 34424739 DOI: 10.1161/strokeaha.121.034392] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.
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Affiliation(s)
| | - Rui Song
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Milan Samarage
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Ian McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Xiangnan Zhang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY
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50
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Sondag L, Jacobs FA, Schreuder FH, Boogaarts JD, Peter Vandertop W, Dammers R, Klijn CJ. Variation in medical management and neurosurgical treatment of patients with supratentorial spontaneous intracerebral haemorrhage. Eur Stroke J 2021; 6:134-142. [PMID: 34414288 PMCID: PMC8370071 DOI: 10.1177/23969873211005915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The role of surgery in spontaneous intracerebral haemorrhage (sICH) remains controversial. This leads to variation in the percentage of patients who are treated with surgery between countries. Patients and methods We sent an online survey to all neurosurgeons (n = 140) and to a sample of neurologists (n = 378) in Dutch hospitals, with questions on management in supratentorial sICH in general, and on treatment in six patients, to explore current variation in medical and neurosurgical management. We assessed patient and haemorrhage characteristics influencing treatment decisions. Results Twenty-nine (21%) neurosurgeons and 92 (24%) neurologists responded. Prior to surgery, neurosurgeons would more frequently administer platelet-transfusion in patients on clopidogrel (64% versus 13%; p = 0.000) or acetylsalicylic acid (61% versus 11%; p = 0.000) than neurologists. In the cases, neurosurgeons and neurologists were similar in their choice for surgery as initial treatment (24% and 31%; p = 0.12), however variation existed amongst physicians in specific cases. Neurosurgeons preferred craniotomy with haematoma evacuation (74%) above minimally-invasive techniques (5%). Age, Glasgow Coma Scale score and ICH location were important factors influencing decisions on treatment for neurosurgeons and neurologists. 69% of neurosurgeons and 80% of neurologists would randomise patients in a trial evaluating the effect of minimally-invasive surgery on functional outcome. Discussion Our results reflect the lack of evidence about the right treatment strategy in patients with sICH. Conclusion New high quality evidence is needed to guide treatment decisions for patients with ICH. The willingness to randomise patients into a clinical trial on minimally-invasive surgery, contributes to the feasibility of such studies in the future.
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Affiliation(s)
- Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floor Ae Jacobs
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Floris Hbm Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jeroen D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - W Peter Vandertop
- Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, VU University Medical Centre, Amsterdam, the Netherlands.,Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Academic Medical Centre, Amsterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
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