2005
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Bowry R, Parker S, Rajan SS, Yamal JM, Wu TC, Richardson L, Noser E, Persse D, Jackson K, Grotta JC. Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management: The BEST-MSU Study Run-In Phase. Stroke 2015; 46:3370-4. [PMID: 26508753 DOI: 10.1161/strokeaha.115.011093] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics. METHODS The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases. RESULTS Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%. CONCLUSIONS The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.
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Affiliation(s)
- Ritvij Bowry
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Stephanie Parker
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Suja S Rajan
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Jose-Miguel Yamal
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Tzu-Ching Wu
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Laura Richardson
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Elizabeth Noser
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - David Persse
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - Kamilah Jackson
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
| | - James C Grotta
- From the Department of Neurology (R.B., S.P., T.-C.W., E.N., K.J.), School of Public Heath (S.S.R., J.-M.Y.), and Department of Emergency Medicine (D.P.), University of Texas Health Science Center, Houston; Frazer Ltd, Houston, TX (L.R.); and Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.).
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2006
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Sato S, Carcel C, Anderson CS. Blood Pressure Management After Intracerebral Hemorrhage. Curr Treat Options Neurol 2015; 17:49. [PMID: 26478247 DOI: 10.1007/s11940-015-0382-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OPINION STATEMENT Elevated blood pressure (BP), which presents in approximately 80 % of patients with acute intracerebral hemorrhage (ICH), is associated with increased risk of poor outcome. The Second Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT2) study, a multinational, multicenter, randomized controlled trial published in 2013, demonstrated better functional outcomes with no harm for patients with acute spontaneous ICH within 6 h of onset who received target-driven, early intensive BP lowering (systolic BP target <140 mmHg within 1 h, continued for 7 days) and suggested that greater and faster reduction in BP might enhance the treatment effect by limiting hematoma growth. The trial resulted in revisions of guidelines for acute management of ICH, in which intensive BP lowering in patients with acute ICH is recommended as safe and effective treatment for improving functional outcome. BP lowering is also the only intervention that is proven to reduce the risk of recurrent ICH. Current evidences from several randomized trials, including PROGRESS and SPS3, indicate that long-term strict BP control in patients with ICH is safe and could offer additional benefits in major reduction in risk of recurrent ICH. The latest American Heart Association/American Stroke Association (AHA/ASA) guidelines recommended a target BP of <130/80 mmHg after ICH, but supporting evidence is limited. Randomized controlled trials are needed that focus on strict BP control, initiated early after onset of the disease and continued long-term, to demonstrate effective prevention of recurrent stroke and other major vascular events without additional harms in the ICH population.
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Affiliation(s)
- Shoichiro Sato
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia
| | - Cheryl Carcel
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia.,Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, 2006, NSW, Australia.,Royal Prince Alfred Hospital, Level 11, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia
| | - Craig S Anderson
- Neurological & Mental Health Division, The George Institute for Global Health, Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia. .,Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, 2006, NSW, Australia. .,Royal Prince Alfred Hospital, Level 11, King George V Building, 83-117 Missenden Rd, Camperdown, Sydney, 2050, NSW, Australia.
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2008
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Wang X, Arima H, Yang J, Zhang S, Wu G, Woodward M, Muñoz-Venturelli P, Lavados PM, Stapf C, Robinson T, Heeley E, Delcourt C, Lindley RI, Parsons M, Chalmers J, Anderson CS. Mannitol and Outcome in Intracerebral Hemorrhage. Stroke 2015; 46:2762-7. [PMID: 26265125 DOI: 10.1161/strokeaha.115.009357] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 07/10/2015] [Indexed: 02/05/2023]
Abstract
Background and Purpose—
Mannitol is often used to reduce cerebral edema in acute intracerebral hemorrhage but without strong supporting evidence of benefit. We aimed to determine the impact of mannitol on outcome among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2).
Methods—
INTERACT2 was an international, open, blinded end point, randomized controlled trial of 2839 patients with spontaneous intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure allocated to intensive (target systolic blood pressure, <140 mm Hg within 1 hour) or guideline-recommended (target systolic blood pressure, <180 mm Hg) blood pressure–lowering treatment. Propensity score and multivariable analyses were performed to investigate the relationship between mannitol treatment (within 7 days) and poor outcome, defined by death or major disability on the modified Rankin Scale score (3–6) at 90 days.
Results—
There was no significant difference in poor outcome between mannitol (n=1533) and nonmannitol (n=993) groups: propensity score–matched odds ratio of 0.90 (95% confidence interval, 0.75–1.09;
P
=0.30) and multivariable odds ratio of 0.87 (95% confidence interval, 0.71–1.07;
P
=0.18). Although a better outcome was suggested in patients with larger (≥15 mL) than those with smaller (<15 mL) baseline hematomas who received mannitol (odds ratio, 0.52 [95% confidence interval, 0.35–0.78] versus odds ratio, 0.91 [95% confidence interval, 0.72–1.15];
P
homogeneity <0.03 in propensity score analyses), the association was not consistent in analyses across other cutoff points (≥10 and ≥20 mL) and for differing grades of neurological severity. Mannitol was not associated with excess serious adverse events.
Conclusions—
Mannitol seems safe but might not improve outcome in patients with acute intracerebral hemorrhage.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00716079.
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Affiliation(s)
- Xia Wang
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Hisatomi Arima
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Jie Yang
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Shihong Zhang
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Guojun Wu
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Mark Woodward
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Paula Muñoz-Venturelli
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Pablo M. Lavados
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Christian Stapf
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Thompson Robinson
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Emma Heeley
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Candice Delcourt
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Richard I. Lindley
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Mark Parsons
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - John Chalmers
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
| | - Craig S. Anderson
- From The George Institute for Global Health, School of Public Health, the University of Sydney, Sydney, Australia (X.W., H.A., M.W., P.M.-V., E.H., C.D., R.I.L., J.C., C.S.A.); Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia (C.D., C.S.A.); Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China (J.Y.); Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.Z.); Department of Neurology, Hebei Yutian Hospital,
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