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Tjerkstra MA, Post R, Germans MR, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Wolfs JFC, De Beer FC, Kieft HH, Nanda D, Van Der Pol B, Roks G, De Beer F, Reichman LJA, Brouwers PJAM, Kwa VIH, Van Der Ree TC, Bienfait HP, Boogaarts HD, Klijn CJ, Visser V, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D. Ultra-Early and Short-Term Tranexamic Acid Treatment in Patients With Good- and Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurology 2024; 102:e209169. [PMID: 38788175 PMCID: PMC11226311 DOI: 10.1212/wnl.0000000000209169] [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] [Received: 06/23/2023] [Accepted: 01/09/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The results of the ULTRA trial showed that ultra-early and short-term treatment with tranexamic acid (TXA) does not improve clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Possibly, the lack of a beneficial effect in all patients with aSAH is masked by antagonistic effects of TXA in certain subgroups. In this post hoc subgroup analysis, we investigated the effect of TXA on clinical outcome in patients with good-grade and poor-grade aSAH. METHODS The ULTRA trial was a multicenter, prospective, randomized, controlled, open-label trial with blinded outcome assessment. Participants received ultra-early and short-term TXA in addition to usual care or usual care only. This post hoc subgroup analysis included only ULTRA participants with confirmed aSAH and available World Federation of Neurosurgical Societies (WFNS) grade on admission. Patients were categorized into those with good-grade (WFNS 1-3) and poor-grade (WFNS 4-5) aSAH. The primary outcome was clinical outcome assessed by the modified Rankin scale (mRS). Odds ratios (ORs) and adjusted ORs (aORs) with 95% CIs were calculated using ordinal regression analyses. Analyses were performed using the as-treated principle. In all patients with aSAH, no significant effect modification of TXA on clinical outcome was observed for admission WFNS grade (p = 0.10). RESULTS Of the 812 ULTRA participants, 473 patients had (58%; N = 232 TXA, N = 241 usual care) good-grade and 339 (42%; N = 162 TXA, N = 176 usual care) patients had poor-grade aSAH. In patients with good-grade aSAH, the TXA group had worse clinical outcomes (OR: 0.67, 95% CI 0.48-0.94, aOR 0.68, 95% CI 0.48-0.94) compared with the usual care group. In patients with poor-grade aSAH, clinical outcomes were comparable between treatment groups (OR: 1.04, 95% CI 0.70-1.55, aOR 1.05, 95% CI 0.70-1.56). DISCUSSION This post hoc subgroup analysis provides another important argument against the use of TXA treatment in patients with aSAH, by showing worse clinical outcomes in patients with good-grade aSAH treated with TXA and no clinical benefit of TXA in patients with poor-grade aSAH, compared with patients treated with usual care. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov (NCT02684812; submission date February 18, 2016, first patient enrollment on July 24, 2013). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tranexamic acid, given for <24 hours within the first 24 hours, does not improve the 6-month outcome in good-grade or poor initial-grade aneurysmal SAH.
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Affiliation(s)
- Maud A Tjerkstra
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - René Post
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Menno R Germans
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Mervyn D I Vergouwen
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Korne Jellema
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Radboud W Koot
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Nyika D Kruyt
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Jasper F C Wolfs
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Frits C De Beer
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Hans H Kieft
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Dharmin Nanda
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Bram Van Der Pol
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Gerwin Roks
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Frank De Beer
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Loes J A Reichman
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Paul J A M Brouwers
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Vincent I H Kwa
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Taco C Van Der Ree
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Henri P Bienfait
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Hieronymus D Boogaarts
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Catharina J Klijn
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Victoria Visser
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - René van den Berg
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Bert A Coert
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Janneke Horn
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Charles B L M Majoie
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Gabriël J E Rinkel
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Yvo B W E M Roos
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - W Peter Vandertop
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
| | - Dagmar Verbaan
- From the Department of Neurosurgery (M.A.T., R.P., V.V., B.A.C., W.P.V., D.V.), Amsterdam UMC, University of Amsterdam; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht; Departments of Neurology (K.J.) and Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, Den Haag; Departments of Neurosurgery (R.W.K.) and Neurology (N.D.K.), Leiden University Medical Centre; Departments of Neurosurgery (F.C.B., D.N.) and Intensive Care (H.K.), ISALA Hospital, Zwolle; Departments of Neurosurgery (B.P.) and Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (V.I.H.K.), OLVG, Amsterdam; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.D.B.); Department of Neurology, Donders Institute for Brain, Cognition and Behaviour (C.J.M.K.), Radboud University Medical Centre, Nijmegen; Departments of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Intensive Care (J.H.), and Neurology (Y.B.W.E.M.R.), Amsterdam UMC, University of Amsterdam., the Netherlands
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Cleveland B, Norling B, Wang H, Gandhi V, Price CL, Borofsky MS, Pais V, Dahm P. Tranexamic acid for percutaneous nephrolithotomy. Cochrane Database Syst Rev 2023; 10:CD015122. [PMID: 37882229 PMCID: PMC10600962 DOI: 10.1002/14651858.cd015122.pub2] [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] [Indexed: 10/27/2023]
Abstract
BACKGROUND Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings. OBJECTIVES To assess the effects of TXA in individuals with kidney stones undergoing PCNL. SEARCH METHODS We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs). MAIN RESULTS We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm2. We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I2 = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I2 = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I2 = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I2 = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I2 = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I2 = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I2 = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I2 = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I2 = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days. AUTHORS' CONCLUSIONS Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.
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Affiliation(s)
- Brent Cleveland
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Brett Norling
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Hill Wang
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Carrie L Price
- Albert S. Cook Library, Towson University, Towson, Maryland, USA
| | - Michael S Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vernon Pais
- Department of Surgery, Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Morkos K, Maingard J, Barras C, Kok HK, Hall J, Russell J, Thijs V, Slater LA, Chong W, Chandra R, Jhamb A, Brooks M, Asadi H. Tranexamic acid as a novel adjunct in the management of vessel perforation complicating Endovascular Clot Retrieval. J Stroke Cerebrovasc Dis 2023; 32:107067. [PMID: 37023537 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 04/08/2023] Open
Abstract
AIM To assess the safety and utility of tranexamic acid (TXA) as an adjunct salvage therapy in iatrogenic vessel perforation complicating endovascular clot retrieval. Iatrogenic vessel perforation and extravasation are known and potentially fatal complications of endovascular clot retrieval (ECR). Various methods of establishing haemostasis post perforation have been reported. TXA is widely utilised intraoperatively to reduce bleeding in various surgical specialities. The use of TXA in endovascular procedures has not been previously described in the literature. METHODS Retrospective case control study of all cases that underwent ECR. Cases where arterial rupture occurred were identified. Details of management and functional status at 3 months were recorded. Modified Rankin score (mRS) 0-2 was considered a good functional outcome. Comparison of proportions analysis was performed. RESULTS Of 1378 cases of ECR, rupture complicated 36 (2.6%). TXA was administered in addition to standard care in 11 cases (31%). At 3 months, 4 of 11 cases (36%) where TXA was administered had a good functional outcome compared to 3 of 22 (12%) in the standard care group (P=0.09). Mortality at 3 months occurred in 4 of 11 cases (41.7%) where TXA was administered compared to 16 of 25 (64%) where it was not (P=0.13). CONCLUSION Tranexamic acid administration in iatrogenic vessel rupture was associated with a lower mortality rate and a larger proportion of patients achieving a good functional outcome at 3 months. This effect trended towards but was not statistically significant. TXA administration was not associated with adverse effects.
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Affiliation(s)
- Kerelus Morkos
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.
| | - Julian Maingard
- School of Medicine, Deakin University, Victoria, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Stroke Division, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Christen Barras
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Hong Kuan Kok
- School of Medicine, Deakin University, Victoria, Australia; Interventional Radiology Service, Northern Health Radiology, Epping, Victoria, Australia
| | - Jonathan Hall
- Interventional Neuroradiology Service, Department of Radiology, Austin Health, Heidelberg, Victoria, Australia; Department of Radiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Jeremy Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia; Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Lee-Anne Slater
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Winston Chong
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ronil Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ashu Jhamb
- Department of Radiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Mark Brooks
- Stroke Division, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia; Interventional Neuroradiology Service, Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Hamed Asadi
- School of Medicine, Deakin University, Victoria, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Interventional Neuroradiology Service, Department of Radiology, Austin Health, Heidelberg, Victoria, Australia; Department of Radiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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A systematic review and meta-analysis of the effects of tranexamic acid in surgical procedure for intracranial meningioma. J Neurooncol 2023; 161:383-393. [PMID: 36633801 DOI: 10.1007/s11060-023-04237-2] [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: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE During intracranial meningioma surgery, surgeons experience considerable blood loss. Tranexamic acid (TXA) is used to minimize blood loss in several neurosurgical settings. However, evidence and trials are lacking. Our objective is to establish the most recent evidence on TXA safety and efficacy in intracranial meningioma surgery. METHODOLOGY Based upon Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors collected fully published English literature on the administration of tranexamic acid for patients undergoing intracranial meningioma surgery using the keywords ["tranexamic acid" and "meningioma"] and its synonyms from Cochrane Central Database, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and PubMed. The primary outcome of the current study was total blood loss. The secondary outcomes include individuals requiring blood transfusion, anesthesia duration, surgical duration, and complication rate. Each included studies' quality was assessed using the JADAD scale. RESULTS For qualitative and quantitative data synthesis, we included five RCTs (n = 321) with the mean age was 47.5 ± 11.9 years for the intervention group and 47.2 ± 11.9 years for the control group. Our meta-analysis showed that the administration of TXA is associated with decreased total blood loss of standardized mean difference (SMD) of -1.40 (95% CI [-2.49, -0.31]), anesthetic time SMD -0.36 (95% CI [-0.63, -0.09]), and blood transfusion requirements RR 0.58 (95% CI [0.34, 0.99]). CONCLUSIONS The current study showed that TXA was associated with reduced intraoperative blood loss and intra- and postoperative blood transfusion. However, the studies are small. More RCT studies with a greater sample size are favorable.
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Germans MR, Dronkers WJ, Baharoglu MI, Post R, Verbaan D, Rinkel GJ, Roos YB. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2022; 11:CD001245. [PMID: 36350005 PMCID: PMC9644641 DOI: 10.1002/14651858.cd001245.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to the dissolution of the blood clot at the site of the aneurysm rupture by natural fibrinolytic activity. This review is an update of previously published Cochrane Reviews. OBJECTIVES To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2022), CENTRAL (in the Cochrane Library 2021, Issue 1), MEDLINE (December 2012 to May 2022), and Embase (December 2012 to May 2022). In an effort to identify further published, unpublished, and ongoing studies, we searched reference lists and trial registers, performed forward tracking of relevant references, and contacted drug companies (the latter in previous versions of this review). SELECTION CRITERIA Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause. DATA COLLECTION AND ANALYSIS Two review authors (MRG & WJD) independently selected trials for inclusion, and extracted the data for the current update. In total, three review authors (MIB & MRG in the previous update; MRG & WJD in the current update) assessed risk of bias. For the primary outcome, we dichotomised the outcome scales into good and poor outcome, with poor outcome defined as death, vegetative state, or (moderate) severe disability, assessed with either the Glasgow Outcome Scale or the Modified Rankin Scale. We assessed death from any cause, rates of rebleeding, delayed cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. We assessed the quality of the evidence with GRADE. MAIN RESULTS We included one new trial in this update, for a total of 11 included trials involving 2717 participants. The risk of bias was low in six studies. Five studies were open label, and we rated them at high risk of performance bias. We also rated one of these studies at high risk for attrition and reporting bias. Five trials reported on poor outcome (death, vegetative state, or (moderate) severe disability), with a pooled risk ratio (RR) of 1.03 (95% confidence interval (CI) 0.94 to 1.13; P = 0.53; 5 trials, 2359 participants; high-quality evidence), which showed no difference between groups. All trials reported on death from all causes, which showed no difference between groups, with a pooled RR of 1.02 (95% CI 0.90 to 1.16; P = 0.77; 11 trials, 2717 participants; high-quality evidence). In trials that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for delayed cerebral ischaemia, the RR for poor outcome was 0.98 (95% CI 0.81 to 1.18; P = 0.83; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment reduced the risk of rebleeding, reported at the end of follow-up (RR 0.65, 95% CI 0.47 to 0.91; P = 0.01; 11 trials, 2717 participants; absolute risk reduction 7%, 95% CI 3 to 12%; moderate-quality evidence), but there was heterogeneity (I² = 59%) between the trials. The pooled RR for delayed cerebral ischaemia was 1.27 (95% CI 1.00 to 1.62; P = 0.05; 7 trials, 2484 participants; moderate-quality evidence). However, this effect was less extreme after the implementation of ischaemia preventative measures and < 72 hours of treatment (RR 1.10, 95% CI 0.83 to 1.46; P = 0.49; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus (RR 1.09, 95% CI 0.99 to 1.20; P = 0.09; 6 trials, 1992 participants; high-quality evidence). AUTHORS' CONCLUSIONS The current evidence does not support the routine use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage. More specifically, early administration with concomitant treatment strategies to prevent delayed cerebral ischaemia does not improve clinical outcome. There is sufficient evidence from multiple randomised controlled trials to incorporate this conclusion in treatment guidelines.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Wouter J Dronkers
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Merih I Baharoglu
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
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Wang X, Zhang Y, Chong W, Hai Y, Wang P, Deng H, You C, Fang F. Association of Rebleeding and Delayed Cerebral Ischemia with Long-term Mortality Among 1-year Survivors After Aneurysmal Subarachnoid Hemorrhage. Curr Neurovasc Res 2022; 19:282-292. [PMID: 35996234 DOI: 10.2174/1567202619666220822105510] [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: 06/16/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE The potential impact of rebleeding and Delayed Cerebral Ischemia (DCI) on long-term survival in patients with aneurysmal subarachnoid hemorrhage (aSAH) remained unclear. This study aimed to investigate whether DCI and rebleeding increase the risk of long-term all-cause mortality in patients with aSAH who survived the follow-up period of one year. METHODS We retrospectively collected data on patients with atraumatic aSAH who were still alive 12 months after aSAH occurrence between December 2013 and June 2019 from the electronic health system. Patients were then classified by the occurrence of rebleeding or DCI during hospitalization. Death records were obtained from an administrative database, the Chinese Household Registration Administration System, until April 20, 2021. Multivariable Cox proportional hazards models were used to compare overall survival in different groups. Sensitivity analysis was performed with propensity-score matching (PSM). RESULTS A total of 2,607 patients were alive one year after aSAH. The crude annual death rate from any cause among patients who had rebleeding (7.2 per 100 person-years) and patients who had DCI (3.7 per 100 person-years) during hospitalization was higher than that of patients with neither event (2.1 per 100 person-years). Multivariate analysis showed that rebleeding is an independent risk factor for long-term mortality (adjusted hazard ratio (aHR), 2.37; 95% confidence interval (CI), 1.47- 3.81). DCI was an independent prognostic factor of poorer overall survival (aHR, 2.09; 95% CI, 1.54-2.84). CONCLUSION Amongst patients alive one year after aSAH, rebleeding and DCI during hospitalization were independently associated with higher rates of long-term mortality.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, 19144 USA
| | - Yang Hai
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19144 USA
| | - Peng Wang
- Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- Department of Neurosurgery, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Marazzi TBM, Mendes PV. Updates on aneurysmal subarachnoid hemorrhage: is there anything really new? ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:80-87. [PMID: 35976291 PMCID: PMC9491434 DOI: 10.1590/0004-282x-anp-2022-s101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe disease, with systemic involvement and complex diagnosis and treatment. Since the current guidelines were published by the AHA/ASA, Neurocritical Care Society and the European Stroke Organization in 2012-2013,there has been an evolution in the comprehension of SAH-associated brain injury and its multiple underlying mechanisms. As a result, several clinical and translational trials were developed or are underway. Objective: The aim of this article is to review some updates in the diagnosis and treatment of neurological complications of SAH. Methods: A review of PubMed (May, 2010 to February, 2022) was performed. Data was summarized. Results: Content of five meta-analyses, nine review articles and 23 new clinical trials, including pilots, were summarized. Conclusions:Advances in the comprehension of pathophysiology and improvements in critical care have been reflected in the reduction of mortality in SAH. However, despite the number of publications, the only treatments shown to be effective in adequate, well-controlled clinical trials are nimodipine and repair of the ruptured aneurysm. Thus, doubts about the optimal management of SAH still persist.
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Affiliation(s)
| | - Pedro Vitale Mendes
- Universidade de São Paulo, Departamento de Emergências Clínicas, São Paulo SP, Brazil
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Ren J, Qian D, Wu J, Ni L, Qian W, Zhao G, Huang C, Liu X, Zou Y, Xing W. Safety and Efficacy of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2022; 12:710495. [PMID: 35140671 PMCID: PMC8818684 DOI: 10.3389/fneur.2021.710495] [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: 06/13/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn recent decades, tranexamic acid (TXA) antifibrinolytic therapy before aneurysm clipping or embolization has been widely reported, but its safety and efficacy remain controversial. This meta-analysis evaluated the efficacy and safety of TXA therapy in aneurysmal subarachnoid hemorrhage (aSAH) patients, aiming to improve the evidence-based medical knowledge of treatment options for such patients.MethodsPubmed, Web of Science, and Cochrane Library databases were searched up to 1 March 2021 for randomized controlled trials (RCTs). We extracted safety and efficacy outcomes and performed a meta-analysis using the Review Manager software. We performed two group analyses of TXA duration and daily dose.ResultsTen RCT studies, enrolling a total of 2,810 participants (1,410 with and 1,400 without TXA therapy), matched the selection criteria. In the TXA duration group: TXA did not reduce overall mortality during the follow-up period [RR 1.00 (95% CI 0.81–1.22)]. The overall rebleeding rate in the TXA group was 0.53 times that of the control group, which was statistically significant [RR 0.53 (95% CI 0.39–0.71)]. However, an RR of 0.43 was not statistically significant in the subgroup analysis of short-term therapy [RR 0.43 (95% CI 0.13–1.39)]. The overall incidence of hydrocephalus was significantly higher in the TXA group than in the control group [RR 1.13 (95% CI 1.02–1.24)]. However, the trend was not statistically significant in the subgroup analysis [short-term: RR 1.10 (95% CI 0.99–1.23); long-term: RR 1.22 (95% CI 0.99–1.50)]. Treatment with TXA did not cause significant delayed cerebral ischemia [RR 1.18 (95% CI 0.89–1.56)], and its subgroup analysis showed an opposite and insignificant effect [short-term: RR 0.99 (95% CI 0.79–1.25); long-term: RR 1.38 (95% CI 0.86–2.21)]. Results in the daily dose group were consistent with those in the TXA duration group.ConclusionsTranexamic acid does not reduce overall mortality in patients with aSAH, nor does it increase the incidence of delayed cerebral ischemia. Tranexamic acid in treating aSAH can reduce the incidence of rebleeding. However, there is no statisticalsignificance in the ultra-early short-term and low daily dose TXA therapy, which may be due to the lack of relevant studies, and more RCT experiments are needed for further study.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO, identifier: 244079.
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Affiliation(s)
- Junwei Ren
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Dongxi Qian
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Jiaming Wu
- Department of Gastroenterology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Lingyan Ni
- Department of Neurology, The First People's Hospital of Taicang, Suzhou, China
| | - Wei Qian
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Guozheng Zhao
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Chuanjun Huang
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Xing Liu
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Yu Zou
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
| | - Weikang Xing
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, China
- *Correspondence: Weikang Xing ;
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10
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Shi M, Yang C, Chen ZH, Xiao LF, Zhao WY. Efficacy and Safety of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 8:790149. [PMID: 35083272 PMCID: PMC8784421 DOI: 10.3389/fsurg.2021.790149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022] Open
Abstract
Tranexamic acid has been shown to reduce rebleeding after aneurysmal subarachnoid hemorrhage; however, whether it can reduce mortality and improve clinical outcomes is controversial. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of the tranexamic acid in aneurysmal subarachnoid hemorrhage. We conducted a comprehensive literature search of PubMed, Embase, Web of Science, and Cochrane Library from inception to March 2021 for randomized controlled trials (RCTs) comparing tranexamic acid and placebo in adults with aneurysmal subarachnoid hemorrhage. The risk of bias was evaluated using the Cochrane Handbook, and the quality of evidence was evaluated using the GRADE approach. This meta-analysis included 13 RCTs, involving 2,888 patients. In patients with aneurysmal subarachnoid hemorrhage tranexamic acid had no significant effect on all-cause mortality (RR = 0.96; 95% CI = 0.84–1.10, p = 0.55, I2 = 44%) or poor functional outcome (RR = 1.04; 95% CI = 0.95–1.15, p = 0.41) compared with the control group. However, risk of rebleeding was significantly lower (RR = 0.59; 95% CI = 0.43–0.80, p = 0.0007, I2 = 53%). There were no significant differences in other adverse events between tranexamic acid and control treatments, including cerebral ischemia (RR = 1.17; 95% CI = 0.95–1.46, p = 0.15, I2 = 53%). At present, routine use of tranexamic acid after subarachnoid hemorrhage cannot be recommended. For a patient with subarachnoid hemorrhage, it is essential to obliterate the aneurysm as early as possible. Additional higher-quality studies are needed to further assess the effect of tranexamic acid on patients with subarachnoid hemorrhage.
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Affiliation(s)
- Min Shi
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chao Yang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zu-han Chen
- Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ling-fei Xiao
- Department of Orthopaedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen-yuan Zhao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Wen-yuan Zhao
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11
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Jiao X, Li M, Li L, Hu X, Guo X, Lu Y. Early Tranexamic Acid in Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2021; 12:721125. [PMID: 34938253 PMCID: PMC8685213 DOI: 10.3389/fneur.2021.721125] [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: 06/06/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Intracranial hemorrhage (ICH) is a common complication of traumatic brain, in which tranexamic acid has been recommended as an additional therapy to prevent a second bleeding. However, the effect of early administration of tranexamic acid for ICH patients remains controversial. Methods: A systematic search was performed in Cochrane Library, Medline, Embase, and Web of Science. Poor outcome refers to significant hemorrhage growth, new intracranial hemorrhage, new focal cerebral ischaemic lesions, the need for neurosurgery, or death. Study heterogeneity and publication bias were estimated. Results: Seven randomized controlled trials involving 3,192 participants were included in our meta-analysis. Tranexamic acid administration in ICH patients was associated with better outcomes of hematoma expansion (odd ratios [OR] 0.79; 95% confidence interval (CI) CI, 0.67–0.93; I2 = 0%; P = 0.006) and growth of hemorrhagic lesions (weighted mean difference [WMD], −1.97 ml; 95% CI, −2.94 to −1.00; I2 = 14%; P < 0.001) than the placebo. No difference was found between the mortality, poor outcome, neurosurgical intervention, new bleeding, and the duration of hospital stay. Moreover, no publication bias was found. Conclusion: Our analysis reveals that the early treatment with tranexamic acid can significantly reduce the incidence of hematoma expansion and the volume of hemorrhagic lesion, but does not exert considerable effects on mortality, poor outcome, neurosurgery, rebleeding, and the duration of stay.
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Affiliation(s)
- Xu Jiao
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mingfei Li
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lulu Li
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinyu Hu
- Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xiaohui Guo
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yun Lu
- Emergency Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Clinical Medical School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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12
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Wu B, Lu Y, Yu Y, Yue H, Wang J, Chong Y, Cui W. Effect of tranexamic acid on the prognosis of patients with traumatic brain injury undergoing craniotomy: study protocol for a randomised controlled trial. BMJ Open 2021; 11:e049839. [PMID: 34824110 PMCID: PMC8627390 DOI: 10.1136/bmjopen-2021-049839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Abnormal coagulation function aggravates the prognosis of patients with traumatic brain injury (TBI). It was reported that the antifibrinolytic drug tranexamic acid (TXA) could reduce intracranial haemorrhage and mortality in non-operative patients with TBI. However, there is a lack of evaluation of TXA in patients with TBI undergoing craniotomy. METHODS AND ANALYSIS This is a single-centre randomised controlled, double-blind, parallel study aiming to investigate the effectiveness and safety of TXA in patients with TBI during the perioperative period. Blood loss and transfusion, neurological function, adverse events, mortality and serum immune-inflammatory cytokines will be collected and analysed. ETHICS AND DISSEMINATION Ethical approval has been granted by the Medical Ethics Committee of Beijing Tian Tan Hospital, Capital Medical University (reference number KY 2020-136-03). The results of this study will be disseminated through presentations at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2100041911.
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Affiliation(s)
- Bei Wu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yu Lu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yun Yu
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Hongli Yue
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Yingzi Chong
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
| | - Weihua Cui
- Department of Anaesthesiology, Beijing Tian Tan hospital, Capital Medical University, Beijing, China
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13
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Cochrane Database Syst Rev 2021; 11:CD013096. [PMID: 34787310 PMCID: PMC8596376 DOI: 10.1002/14651858.cd013096.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Subarachnoid haemorrhage has an incidence of up to nine per 100,000 person-years. It carries a mortality of 30% to 45% and leaves 20% dependent in activities of daily living. The major causes of death or disability after the haemorrhage are delayed cerebral ischaemia and rebleeding. Interventions aimed at lowering blood pressure may reduce the risk of rebleeding, while the induction of hypertension may reduce the risk of delayed cerebral ischaemia. Despite the fact that medical alteration of blood pressure has been clinical practice for more than three decades, no previous systematic reviews have assessed the beneficial and harmful effects of altering blood pressure (induced hypertension or lowered blood pressure) in people with acute subarachnoid haemorrhage. OBJECTIVES To assess the beneficial and harmful effects of altering arterial blood pressure (induced hypertension or lowered blood pressure) in people with acute subarachnoid haemorrhage. SEARCH METHODS We searched the following from inception to 8 September 2020 (Chinese databases to 27 January 2019): Cochrane Stroke Group Trials register; CENTRAL; MEDLINE; Embase; five other databases, and five trial registries. We screened reference lists of review articles and relevant randomised clinical trials. SELECTION CRITERIA Randomised clinical trials assessing the effects of inducing hypertension or lowering blood pressure in people with acute subarachnoid haemorrhage. We included trials irrespective of publication type, status, date, and language. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed the risk of bias of all included trials to control for the risk of systematic errors. We performed trial sequential analysis to control for the risks of random errors. We also applied GRADE. Our primary outcomes were death from all causes and death or dependency. Our secondary outcomes were serious adverse events, quality of life, rebleeding, delayed cerebral ischaemia, and hydrocephalus. We assessed all outcomes closest to three months' follow-up (primary point of interest) and maximum follow-up. MAIN RESULTS We included three trials: two trials randomising 61 participants to induced hypertension versus no intervention, and one trial randomising 224 participants to lowered blood pressure versus placebo. All trials were at high risk of bias. The certainty of the evidence was very low for all outcomes. Induced hypertension versus control Two trials randomised participants to induced hypertension versus no intervention. Meta-analysis showed no evidence of a difference between induced hypertension versus no intervention on death from all causes (risk ratio (RR) 1.60, 95% confidence interval (CI) 0.57 to 4.42; P = 0.38; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analyses showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. Meta-analysis showed no evidence of a difference between induced hypertension versus no intervention on death or dependency (RR 1.29, 95% CI 0.78 to 2.13; P = 0.33; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analyses showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. Meta-analysis showed no evidence of a difference between induced hypertension and control on serious adverse events (RR 2.24, 95% CI 1.01 to 4.99; P = 0.05; I2 = 0%; 2 trials, 61 participants; very low-certainty evidence). Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. One trial (41 participants) reported quality of life using the Stroke Specific Quality of Life Scale. The induced hypertension group had a median of 47 points (interquartile range 35 to 55) and the no-intervention group had a median of 49 points (interquartile range 35 to 55). The certainty of evidence was very low. One trial (41 participants) reported rebleeding. Fisher's exact test (P = 1.0) showed no evidence of a difference between induced hypertension and no intervention on rebleeding. The certainty of evidence was very low. Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. One trial (20 participants) reported delayed cerebral ischaemia. Fisher's exact test (P = 1.0) showed no evidence of a difference between induced hypertension and no intervention on delayed cerebral ischaemia. The certainty of the evidence was very low. Trial sequential analysis showed that we had insufficient information to confirm or reject our predefined relative risk reduction of 20% or more. None of the trials randomising participants to induced hypertension versus no intervention reported on hydrocephalus. No subgroup analyses could be conducted for trials randomising participants to induced hypertension versus no intervention. Lowered blood pressure versus control One trial randomised 224 participants to lowered blood pressure versus placebo. The trial only reported on death from all causes. Fisher's exact test (P = 0.058) showed no evidence of a difference between lowered blood pressure versus placebo on death from all causes. The certainty of evidence was very low. AUTHORS' CONCLUSIONS Based on the current evidence, there is a lack of information needed to confirm or reject minimally important intervention effects on patient-important outcomes for both induced hypertension and lowered blood pressure. There is an urgent need for trials assessing the effects of altering blood pressure in people with acute subarachnoid haemorrhage. Such trials should use the SPIRIT statement for their design and the CONSORT statement for their reporting. Moreover, such trials should use methods allowing for blinded altering of blood pressure and report on patient-important outcomes such as mortality, rebleeding, delayed cerebral ischaemia, quality of life, hydrocephalus, and serious adverse events.
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Affiliation(s)
- Mathias Maagaard
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - William K Karlsson
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen NV, Denmark
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus C Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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14
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Murao S, Nakata H, Roberts I, Yamakawa K. Effect of tranexamic acid on thrombotic events and seizures in bleeding patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:380. [PMID: 34724964 PMCID: PMC8561958 DOI: 10.1186/s13054-021-03799-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) reduces surgical bleeding and reduces death from bleeding after trauma and childbirth. However, its effects on thrombotic events and seizures are less clear. We conducted a systematic review and meta-analysis to examine the safety of TXA in bleeding patients. METHODS For this systematic review and meta-analysis, we searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled trials from inception until June 1, 2020. We included randomized trials comparing intravenous tranexamic acid and placebo or no intervention in bleeding patients. The primary outcomes were thrombotic events, venous thromboembolism, acute coronary syndrome, stroke and seizures. A meta-analysis was performed using a random effects model and meta-regression analysis was performed to evaluate how effects vary by dose. We assessed the certainty of evidence using the grading of recommendations, assessment, development and evaluations (GRADE) approach. RESULTS A total of 234 studies with 102,681 patients were included in the meta-analysis. In bleeding patients, there was no evidence that TXA increased the risk of thrombotic events (RR = 1.00 [95% CI 0.93-1.08]), seizures (1.18 [0.91-1.53]), venous thromboembolism (1.04 [0.92-1.17]), acute coronary syndrome (0.88 [0.78-1.00]) or stroke (1.12 [0.98-1.27]). In a dose-by-dose sensitivity analysis, seizures were increased in patients receiving more than 2 g/day of TXA (3.05 [1.01-9.20]). Meta-regression showed an increased risk of seizures with increased dose of TXA (p = 0.011). CONCLUSION Tranexamic acid did not appear to increase the risk of thrombotic events in bleeding patients. However, because there may be dose-dependent increase in the risk of seizures, very high doses should be avoided.
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Affiliation(s)
- Shuhei Murao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Hidekazu Nakata
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi, Osaka, 558-8558, Japan
| | - Ian Roberts
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
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15
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Neurosurgical intensive care medicine : Intensive medical care studies from 2020/2021]. Anaesthesist 2021; 70:789-794. [PMID: 34378066 DOI: 10.1007/s00101-021-00978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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16
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Relke N, Chornenki NLJ, Sholzberg M. Tranexamic acid evidence and controversies: An illustrated review. Res Pract Thromb Haemost 2021; 5:e12546. [PMID: 34278187 PMCID: PMC8279901 DOI: 10.1002/rth2.12546] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 12/23/2022] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.
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Affiliation(s)
- Nicole Relke
- Department of MedicineQueen's UniversityKingstonONCanada
| | | | - Michelle Sholzberg
- Department of MedicineSt. Michael's HospitalUniversity of TorontoTorontoONCanada
- Department of Laboratory Medicine & PathobiologySt. Michael's HospitalUniversity of TorontoTorontoONCanada
- Division of HematologyDepartment of MedicineSt. Michael's HospitalUniversity of TorontoTorontoONCanada
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17
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Patel S, Parikh A, Okorie ON. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med 2021; 14:31. [PMID: 33980142 PMCID: PMC8117305 DOI: 10.1186/s12245-021-00353-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/22/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician. DISCUSSION The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest. CONCLUSION Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.
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Affiliation(s)
- Sima Patel
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA.
| | - Amay Parikh
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Okorie Nduka Okorie
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA
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18
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Lo BWY, Fukuda H, Tsang ACO, Langer DJ, Miyawaki S, Koyanagi M, Lui MWM. Commentary on Post, et al. Ultra-early tranexamic acid after subarachnoid hemorrhage: A randomized controlled trial. Lancet 2021. Surg Neurol Int 2021; 12:156. [PMID: 33948326 PMCID: PMC8088487 DOI: 10.25259/sni_242_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022] Open
Abstract
Background Tranexamic acid (TA) administration in aneurysmal subarachnoid hemorrhage (SAH) within the first 24 hours may reduce the incidence of early aneurysmal rebleeding. However, this is also the potential for an increased risk of delayed cerebral ischemia if TA is administered for more than 72 hours following the initial aneurysmal rupture. Methods In the ultra-early tranexamic acid after subarachnoid hemorrhage randomized controlled trial by Post et al., patients were randomized to receive TA within the first 24 hours, or until start of aneurysm treatment. These results were compared to a matched control group. Results Ultra-early administration (≤24 h) of TA reduced the incidence of rebleeding, and did not alter the incidence of delayed cerebral ischemia and/or extracranial thrombosis. Further, no significant differences were noted between the TA group and control arm in the incidence of good (modified Rankin scores 0-3) clinical outcomes at 6 months. Conclusion Ultra-early administration of TA (≤24 h) resulted in a lower rate of recurrent hemorrhage, without increasing the incidence of delayed cerebral ischemia in SAH patients.
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Affiliation(s)
- Benjamin W Y Lo
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, United States
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Kochi, Japan
| | - Anderson C O Tsang
- Department of Surgery, Division of Neurosurgery, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, United States
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo
| | - Masaomi Koyanagi
- Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Kyoto University, Amagasaki City, Hyogo, Japan
| | - Matthew Wai-Man Lui
- Department of Surgery, Division of Neurosurgery, Queen Mary Hospital, University of Hong Kong, Hong Kong
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19
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Lu VM, Graffeo CS, Perry A, Carlstrom LP, Casabella AM, Wijdicks EFM, Lanzino G, Rabinstein AA. Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study. J Clin Neurosci 2020; 81:180-185. [PMID: 33222913 DOI: 10.1016/j.jocn.2020.09.064] [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: 07/04/2020] [Revised: 09/09/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood. METHODS A retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores. RESULTS Of 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3-5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3-5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome. CONCLUSIONS Early rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States.
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanda M Casabella
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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20
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Wise R, Bishop D, Gibbs M, Govender K, James MFM, Kabambi F, Louw V, Mdladla N, Moipalai L, Motchabi-Chakane P, Nolte D, Rodseth R, Schneider F, Turton E. South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
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Affiliation(s)
- R Wise
- University of KwaZulu-Natal
| | | | | | | | | | | | | | - N Mdladla
- Sefako Makgatho Health Sciences University
| | | | | | - D Nolte
- University of the Witwatersrand
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21
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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22
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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 : Intensive medical care studies from 2019/2020]. Anaesthesist 2020; 70:78-82. [PMID: 33026505 DOI: 10.1007/s00101-020-00858-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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23
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Sprigg N, Flaherty K, Appleton JP, Al-Shahi Salman R, Bereczki D, Beridze M, Ciccone A, Collins R, Dineen RA, Duley L, Egea-Guerrero JJ, England TJ, Karlinski M, Krishnan K, Laska AC, Law ZK, Ovesen C, Ozturk S, Pocock SJ, Roberts I, Robinson TG, Roffe C, Peters N, Scutt P, Thanabalan J, Werring D, Whynes D, Woodhouse L, Bath PM. Tranexamic acid to improve functional status in adults with spontaneous intracerebral haemorrhage: the TICH-2 RCT. Health Technol Assess 2020; 23:1-48. [PMID: 31322116 DOI: 10.3310/hta23350] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces death due to bleeding after trauma and postpartum haemorrhage. OBJECTIVE The aim of the study was to assess if tranexamic acid is safe, reduces haematoma expansion and improves outcomes in adults with spontaneous intracerebral haemorrhage (ICH). DESIGN The TICH-2 (Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage) study was a pragmatic, Phase III, prospective, double-blind, randomised placebo-controlled trial. SETTING Acute stroke services at 124 hospitals in 12 countries (Denmark, Georgia, Hungary, Ireland, Italy, Malaysia, Poland, Spain, Sweden, Switzerland, Turkey and the UK). PARTICIPANTS Adult patients (aged ≥ 18 years) with ICH within 8 hours of onset. EXCLUSION CRITERIA Exclusion criteria were ICH secondary to anticoagulation, thrombolysis, trauma or a known underlying structural abnormality; patients for whom tranexamic acid was thought to be contraindicated; prestroke dependence (i.e. patients with a modified Rankin Scale [mRS] score > 4); life expectancy < 3 months; and a Glasgow Coma Scale score of < 5. INTERVENTIONS Participants, allocated by randomisation, received 1 g of an intravenous tranexamic acid bolus followed by an 8-hour 1-g infusion or matching placebo (i.e. 0.9% saline). MAIN OUTCOME MEASURE The primary outcome was functional status (death or dependency) at day 90, which was measured by the shift in the mRS score, using ordinal logistic regression, with adjustment for stratification and minimisation criteria. RESULTS A total of 2325 participants (tranexamic acid, n = 1161; placebo, n = 1164) were recruited from 124 hospitals in 12 countries between 2013 and 2017. Treatment groups were well balanced at baseline. The primary outcome was determined for 2307 participants (tranexamic acid, n = 1152; placebo, n = 1155). There was no statistically significant difference between the treatment groups for the primary outcome of functional status at day 90 [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.76 to 1.03; p = 0.11]. Although there were fewer deaths by day 7 in the tranexamic acid group (aOR 0.73, 95% CI 0.53 to 0.99; p = 0.041), there was no difference in case fatality at 90 days (adjusted hazard ratio 0.92, 95% CI 0.77 to 1.10; p = 0.37). Fewer patients experienced serious adverse events (SAEs) after treatment with tranexamic acid than with placebo by days 2 (p = 0.027), 7 (p = 0.020) and 90 (p = 0.039). There was no increase in thromboembolic events or seizures. LIMITATIONS Despite attempts to enrol patients rapidly, the majority of participants were enrolled and treated > 4.5 hours after stroke onset. Pragmatic inclusion criteria led to a heterogeneous population of participants, some of whom had very large strokes. Although 12 countries enrolled participants, the majority (82.1%) were from the UK. CONCLUSIONS Tranexamic acid did not affect a patient's functional status at 90 days after ICH, despite there being significant modest reductions in early death (by 7 days), haematoma expansion and SAEs, which is consistent with an antifibrinolytic effect. Tranexamic acid was safe, with no increase in thromboembolic events. FUTURE WORK Future work should focus on enrolling and treating patients early after stroke and identify which participants are most likely to benefit from haemostatic therapy. Large randomised trials are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN93732214. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 35. See the NIHR Journals Library website for further project information. The project was also funded by the Pragmatic Trials, UK, funding call and the Swiss Heart Foundation in Switzerland.
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Affiliation(s)
- Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia
| | - Alfonso Ciccone
- Neurology Unit, Azienda Socio Sanitaria Territoriale di Mantova, Mantua, Italy
| | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Juan José Egea-Guerrero
- UGC de Medicina Intensiva, Hospital Universitario Virgen del Rocío, IBiS/CSIC/Universidad de Sevilla, Seville, Spain
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Derby, UK
| | - Michal Karlinski
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Christian Ovesen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christine Roffe
- Stroke Research, Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jegan Thanabalan
- Division of Neurosurgery, Department of Surgery, National University of Malaysia, Kuala Lumpur, Malaysia
| | - David Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences of University College London, University College London, London, UK.,National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Whynes
- School of Economics, University of Nottingham, Nottingham, UK
| | - Lisa Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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24
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Beynon C, Bernhard M, Brenner T, Dietrich M, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus on neurosurgery : Intensive care studies from 2018-2019]. Anaesthesist 2020; 69:205-210. [PMID: 31440787 DOI: 10.1007/s00101-019-00644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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25
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de Faria JL, da Silva Brito J, Costa E Silva LT, Kilesse CTSM, de Souza NB, Pereira CU, Figueiredo EG, Rabelo NN. Tranexamic acid in Neurosurgery: a controversy indication-review. Neurosurg Rev 2020; 44:1287-1298. [PMID: 32556832 DOI: 10.1007/s10143-020-01324-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/01/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
Tranexamic acid (TXA) is one of the measures indicated to reduce bleeding and the need for volume replacement. However, data on risks and benefits are controversial. This study analyzes the effectivity and risks of using tranexamic acid in neurosurgery. We selected articles, published from 1976 to 2019, on the PubMed, EMBASE, Science Direct, and The Cochrane Database using the descriptors: "tranexamic acid," "neurosurgery," "traumatic brain injury," "subdural hemorrhage," "brain aneurysm," and "subarachnoid hemorrhage." TXA can reduce blood loss and the need for blood transfusion in trauma and spinal surgery. Despite the benefits of TXA, moderate-to-high doses are potentially associated with neurological complications (seizures, transient ischemic attack, delirium) in adults and children. In a ruptured intracranial aneurysm, the use of TXA can considerably reduce the risk of rebleeding, but there is weak evidence regarding its influence on mortality reduction. The TXA use in brain surgery does not present benefit. However, this conclusion is limited because there are few studies. TXA in neurosurgeries is a promising method for the maintenance of hemostasis in affected patients, mainly in traumatic brain injury and spinal surgery; nevertheless, there is lack of evidence in brain and vascular surgeries. Many questions remain unanswered, such as how to determine the dosage that triggers the onset of associated complications, or how to adjust the dose for chronic kidney disease patients.
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Affiliation(s)
- José Luiz de Faria
- Department of Neurosurgery, University Center UNiAtenas, Paracatu, Minas Gerais, Brazil
| | - Josué da Silva Brito
- Department of Neurosurgery, University Center UNiAtenas, Paracatu, Minas Gerais, Brazil
| | | | | | | | | | - Eberval Gadelha Figueiredo
- Department of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina, University of Sao Paulo, Sao Paulo, Brazil
| | - Nícollas Nunes Rabelo
- Department of Neurosurgery, University Center UNiAtenas, Paracatu, Minas Gerais, Brazil. .,Department of Neurosurgery, Hospital das Clinicas da Faculdade de Medicina, University of Sao Paulo, Sao Paulo, Brazil.
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26
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Post R, Germans MR, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. Update of the ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage (ULTRA) trial: statistical analysis plan. Trials 2020; 21:199. [PMID: 32070395 PMCID: PMC7029526 DOI: 10.1186/s13063-020-4118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recurrent bleeding from an intracranial aneurysm after subarachnoid hemorrhage (SAH) is associated with unfavorable outcome. Recurrent bleeding before aneurysm occlusion can be performed occurs in up to one in five patients and most often happens within the first 6 h after the primary hemorrhage. Reducing the rate of recurrent bleeding could be a major factor in improving clinical outcome after SAH. Tranexamic acid (TXA) reduces the risk of recurrent bleeding but has thus far not been shown to improve functional outcome, probably because of a higher risk of delayed cerebral ischemia (DCI). To reduce the risk of ultraearly recurrent bleeding, TXA should be administered as soon as possible after diagnosis and before transportation to a tertiary care center. If TXA is administered for a short duration (i.e., < 24 h), it may not increase the risk of DCI. The aim of this paper is to present in detail the statistical analysis plan (SAP) of the ULTRA trial (ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage), which is currently enrolling patients and investigating whether ultraearly and short-term TXA treatment in patients with aneurysmal SAH improves clinical outcome at 6 months. METHODS/DESIGN The ULTRA trial is a multicenter, prospective, randomized, open, blinded endpoint, parallel-group trial currently ongoing at 8 tertiary care centers and 16 of their referral centers in the Netherlands. Participants are randomized to standard care or to receive TXA at a loading dose of 1 g, immediately followed by 1 g every 8 h for a maximum of 24 h, in addition to standard care, as soon as SAH is diagnosed. In the TXA group, TXA administration is stopped immediately prior to treatment (coil or clip) of the causative aneurysm. Primary outcome is the modified Rankin Scale (mRS) score at 6 months after SAH, dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcomes, assessed blind to treatment allocation. Secondary outcomes include case fatalities at 30 days and at 6 months and causes of poor clinical outcome. Safety outcomes are recurrent bleeding, DCI, hydrocephalus, per-procedural complications, and other complications such as infections occurring during hospitalization. Data analyses will be according to this prespecified SAP. TRIAL REGISTRATION Netherlands Trial Register, NTR3272. Registered on 25 January 2012. ClinicalTrials.gov, NCT02684812. Registered on 17 February 2016.
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, PO Box 85060, Utrecht, 3508 AB, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands.
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27
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Andersen CR, Fitzgerald E, Delaney A, Finfer S. A Systematic Review of Outcome Measures Employed in Aneurysmal Subarachnoid Hemorrhage (aSAH) Clinical Research. Neurocrit Care 2020; 30:534-541. [PMID: 29951958 DOI: 10.1007/s12028-018-0566-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Consensus on appropriate outcome measures to use in aneurysmal subarachnoid hemorrhage (aSAH) research has not been established, although the transition toward a core outcome set (COS) would provide significant benefits. To inform COS development, we conducted a systematic review to identify outcome measures included in reports of randomized clinical trials (RCTs) of interventions in patients with aSAH. Ovid Medline, EMBASE, CINAHL, and CENTRAL were searched. RCTs investigating aSAH published between January 1996 and May 2015 were included. The primary and secondary outcomes of RCTs were recorded and classified according to the OMERACT Consortium's framework. We identified 1093 potential studies of which 129 met inclusion criteria representing 24 238 patients. There were 285 unique outcome measures. The Glasgow Outcome Scale (GOS) was the most frequently used primary outcome (13/129, 10.1%). Mortality was reported in 84 trials (65.1%) with 3 months the most common time point (34/129, 26.4%). The GOS (65/129, 50.4%) and the Modified Rankin Scale (51/129, 39.5%) were the most commonly reported functional measures; however, these were reported at different time points and often dichotomized using different ranges. Patient-reported quality of life measures were used in 11 trials (8.5%). Transcranial Doppler was the most frequently used imaging modality (40/129, 31.0%). Definitions and reporting of vasospasm, delayed cerebral ischemia and imaging modality results were highly variable. The marked heterogeneity of outcomes in reports of RCTs supports the development of a core outcome set for aSAH trials. Our study has identified a wide range of outcomes for potential inclusion in a future aSAH COS.
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Affiliation(s)
- Christopher R Andersen
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,Northern Clinical School, Sydney Medical School, University of Sydney, St Leonards, NSW, Australia. .,Division of Critical Care and Trauma, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia. .,Nuffield Department of Clinical Neurosciences, University of Oxford Kadoorie Centre, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Emily Fitzgerald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Northern Clinical School, Sydney Medical School, University of Sydney, St Leonards, NSW, Australia
| | - Simon Finfer
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Division of Critical Care and Trauma, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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28
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Liotta EM, Karmarkar A, Batra A, Kim M, Prabhakaran S, Naidech AM, Maas MB. Magnesium and Hemorrhage Volume in Patients With Aneurysmal Subarachnoid Hemorrhage. Crit Care Med 2020; 48:104-110. [PMID: 31688193 PMCID: PMC7008932 DOI: 10.1097/ccm.0000000000004079] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We tested the hypothesis that admission serum magnesium levels are associated with extent of hemorrhage in patients with aneurysmal subarachnoid hemorrhage. DESIGN Single-center prospective observational study. SETTING Tertiary hospital neurologic ICU. PATIENTS Patients with aneurysmal subarachnoid hemorrhage. INTERVENTIONS Clinically indicated CT scans and serum laboratory studies. MEASUREMENTS AND MAIN RESULTS Demographic, clinical, laboratory, and radiographic data were analyzed. Extent of initial hemorrhage was graded semi-quantitatively on admission CT scans using the modified Fisher scale (grades: 0, no radiographic hemorrhage; 1, thin [< 1 mm in depth] subarachnoid hemorrhage; 2, thin subarachnoid hemorrhage with intraventricular hemorrhage; 3, thick [≥ 1 mm] subarachnoid hemorrhage; 4, thick subarachnoid hemorrhage with intraventricular hemorrhage). We used both ordinal (modified Fisher scale) and dichotomized (thick vs thin subarachnoid hemorrhage) univariate and adjusted logistic regression models to assess associations between serum magnesium and radiographic subarachnoid hemorrhage severity. Data from 354 patients (mean age 55 ± 14 yr, 28.5% male, median admission Glasgow Coma Scale 14 [10-15]) were analyzed. Mean magnesium was lower in patients with thick versus thin subarachnoid hemorrhage (1.92 vs 1.99 mg/dL; p = 0.022). A monotonic trend across categories of modified Fisher scale was found using analysis of variance and Spearman rank correlation (p = 0.015 and p = 0.008, respectively). In adjusted ordinal and binary regression models, lower magnesium levels were associated with higher modified Fisher scale (odds ratio 0.33 per 1 mg/dL increase; 95% CI, 0.14-0.77; p = 0.011) and with thick subarachnoid hemorrhage (odds ratio 0.29 per 1 mg/dL increase; 95% CI, 0.10-0.78; p = 0.015). CONCLUSIONS These data support the hypothesis that magnesium influences hemorrhage severity in patients with aneurysmal subarachnoid hemorrhage, potentially through a hemostatic mechanism.
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Affiliation(s)
- Eric M. Liotta
- Department of Neurology, Northwestern University, Chicago, IL
| | | | - Ayush Batra
- Department of Neurology, Northwestern University, Chicago, IL
| | - Minjee Kim
- Department of Neurology, Northwestern University, Chicago, IL
| | | | | | - Matthew B. Maas
- Department of Neurology, Northwestern University, Chicago, IL
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Kim CH, Lee SW, Kim YH, Sung SK, Son DW, Song GS. Predictors of Hematoma Enlargement in Patients with Spontaneous Intracerebral Hemorrhage Treated with Rapid Administration of Antifibrinolytic Agents and Strict Conservative Management. Korean J Neurotrauma 2019; 15:126-134. [PMID: 31720266 PMCID: PMC6826086 DOI: 10.13004/kjnt.2019.15.e23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/19/2019] [Accepted: 08/20/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Spontaneous intracerebral hemorrhage (ICH) is caused by the rupture of small blood vessels and other health problems. In ICH patients, hematoma enlargement is the most critical risk factor for poor outcomes. Tranexamic acid, an anti-fibrinolytic agent, has been used to reduce hematoma expansion. We analyzed the risk factors for hematoma expansion in ICH patients and compared the predictability of hematoma expansion in ICH patients with the use of tranexamic acid. Methods We performed retrospective analysis of ICH patients who underwent follow-up computed tomography scans from October 2008 to October 2018. Of the 329 included patients, 67 who received tranexamic acid and 262 who did not receive tranexamic acid were compared. We also analyzed the risk factors of 45 and 284 patients who did and did not experience hematoma expansion, respectively. Results Hematoma expansion was observed in 7 (10.4%) of 67 patients in the tranexamic acid group and 38 (14.5%) of the 262 patients who did not receive tranexamic acid. There was no statistically significant difference between patients who did and did not received tranexamic acid (p=0.389). In the multivariate logistic regression analysis of risk factors for hematoma expansion, spot sign and a maximal diameter of 40 mm were identified as risk factors. Conclusion We could not confirm the effect of tranexamic acid on hematoma expansion in ICH patients. Spot sign and the maximal diameter of hematomas were confirmed as risk factors of hematoma expansion. If the maximal diameter is greater than 40 mm, the hematoma should be closely monitored.
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Affiliation(s)
- Chang Hyeun Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ki Sung
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
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Guo J, Gao X, Ma Y, Lv H, Hu W, Zhang S, Ji H, Wang G, Shi J. Different dose regimes and administration methods of tranexamic acid in cardiac surgery: a meta-analysis of randomized trials. BMC Anesthesiol 2019; 19:129. [PMID: 31307381 PMCID: PMC6631782 DOI: 10.1186/s12871-019-0772-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 05/28/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The efficacy of tranexamic acid (TXA) to reduce perioperative blood loss and allogeneic blood transfusion in cardiac surgeries has been proved in previous studies, but its adverse effects especially seizure has always been a problem of concern. This meta-analysis aims to provide information on the optimal dosage and delivery method which is effective with the least adverse outcomes. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE for all relevant articles published before 2018/12/31. Inclusion criteria were adult patients undergoing elective heart surgeries, and only randomized control trials comparing TXA with placebo were considered. Two authors independently assessed trial quality and extracted relevant data. RESULTS We included 49 studies with 10,591 patients into analysis. TXA significantly reduced transfusion rate (RR 0.71, 95% CI 0.65 to 0.78, P<0.00001). The overall transfusion rate was 35%(1573/4477) for patients using TXA and 49%(2190/4408) for patients in the control group. Peri-operative blood loss (MD - 246.98 ml, 95% CI - 287.89 to - 206.06 ml, P<0.00001) and re-operation rate (RR 0.62, 95% CI 0.49 to 0.79, P<0.0001) were also reduced significantly. TXA usage did not increase risk of mortality, myocardial infarction, stroke, pulmonary embolism and renal dysfunction, but was associated with a significantly increase in seizure attack (RR 3.21, 95% CI 1.04 to 9.90, P = 0.04).The overall rate of seizure attack was 0.62%(21/3378) for patients using TXA and 0.15%(5/3406) for patients in the control group. In subgroup analysis, TXA was effective for both on-pump and off-pump surgeries. Topical application didn't reduce the need for transfusion requirement, while intravenous delivery no matter as bolus injection alone or bolus plus continuous infusion were effective. Intravenous high-dose TXA didn't further decrease transfusion rate compared with low-dose regimen, and increased the risk of seizure by 4.83 times. No patients in the low-dose group had seizure attack. CONCLUSIONS TXA was effective in reducing transfusion requirement in all kinds of cardiac surgeries. Low-dose intravenous infusion was the most preferable delivery method which was as effective as high-dose regimen in reducing transfusion rate without increasing the risk of seizure.
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Affiliation(s)
- Jingfei Guo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Xurong Gao
- Department of Blood Transfusion, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Yan Ma
- Operating room, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Huran Lv
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Wenjun Hu
- Department of Anesthesiology, The 305th Hospital of the Chinese People’s Liberation Army, No.13 Wenjin Road, Xicheng district, Beijing, China
| | - Shijie Zhang
- Department of Anesthesiology, Wu’an First People’s Hospital, Kuangjian Road, Handan, Hebei Province China
| | - Hongwen Ji
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
| | - Jia Shi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, No.167 Beilishi Road, Xicheng district, Beijing, China
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Ker K, Prieto-Merino D, Sprigg N, Mahmood A, Bath P, Kang Law Z, Flaherty K, Roberts I. The effectiveness and safety of anti-fibrinolytics in patients with acute intracranial haemorrhage: statistical analysis plan for an individual patient data meta-analysis. Wellcome Open Res 2019; 2:120. [PMID: 29417096 PMCID: PMC5785711 DOI: 10.12688/wellcomeopenres.13262.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 01/11/2023] Open
Abstract
Abstract Introduction: The Anti-fibrinolytics Trialists Collaboration aims to increase knowledge about the effectiveness and safety of anti-fibrinolytic treatment by conducting individual patient data (IPD) meta-analyses of randomised trials. This article presents the statistical analysis plan for an IPD meta-analysis of the effects of anti-fibrinolytics for acute intracranial haemorrhage. Methods: The protocol for the IPD meta-analysis has been registered with PROSPERO (CRD42019128260). We will conduct an individual patient data meta-analysis of randomised controlled trials with 500 patients or more assessing the effects of anti-fibrinolytics in acute intracranial haemorrhage. The primary outcomes will be 1) death from stroke or head injury within 30 days of randomisation, and 2) death from stroke or head injury, or dependency within 90 days of randomisation. The primary outcomes will be limited to patients treated within three hours of injury or stroke onset. We will report treatment effects using odds ratios and 95% confidence intervals. We use logistic regression models to examine how the effect of anti-fibrinolytics vary by time to treatment, severity of intracranial bleeding, and age. We will also examine the effect of anti-fibrinolytics on secondary outcomes including death, dependency, vascular occlusive events, seizures, and neurological outcomes. Secondary outcomes will be assessed in all patients irrespective of time of treatment. All analyses will be conducted on an intention-to-treat basis. Conclusions: This IPD meta-analysis will examine important clinical questions about the effects of anti-fibrinolytic treatment in patients with intracranial haemorrhage that cannot be answered using aggregate data. With IPD we can examine how effects vary by time to treatment, bleeding severity, and age, to gain better understanding of the balance of benefit and harms on which to base recommendations for practice.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - David Prieto-Merino
- Catholic University of Murcia, Campus de los Jeronimos, Murcia, Spain.,London School of Hygiene & Tropical Medicine, London, UK
| | - Nikola Sprigg
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Abda Mahmood
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Bath
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Zhe Kang Law
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Katie Flaherty
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Ker K, Prieto-Merino D, Sprigg N, Mahmood A, Bath P, Kang Law Z, Flaherty K, Roberts I. The effectiveness and safety of anti-fibrinolytics in patients with acute intracranial haemorrhage: statistical analysis plan for an individual patient data meta-analysis. Wellcome Open Res 2019. [PMID: 29417096 DOI: 10.12688/wellcomeopenres.13262.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION The Anti-fibrinolytics Trialists Collaboration aims to increase knowledge about the effectiveness and safety of anti-fibrinolytic treatment by conducting individual patient data (IPD) meta-analyses of randomised trials. This article presents the statistical analysis plan for an IPD meta-analysis of the effects of anti-fibrinolytics for acute intracranial haemorrhage. METHODS The protocol for the IPD meta-analysis has been registered with PROSPERO (CRD42019128260). We will conduct an individual patient data meta-analysis of randomised controlled trials with 500 patients or more assessing the effects of anti-fibrinolytics in acute intracranial haemorrhage. The primary outcomes will be 1) death from stroke or head injury within 30 days of randomisation, and 2) death from stroke or head injury, or dependency within 90 days of randomisation. The primary outcomes will be limited to patients treated within three hours of injury or stroke onset. We will report treatment effects using odds ratios and 95% confidence intervals. We use logistic regression models to examine how the effect of anti-fibrinolytics vary by time to treatment, severity of intracranial bleeding, and age. We will also examine the effect of anti-fibrinolytics on secondary outcomes including death, dependency, vascular occlusive events, seizures, and neurological outcomes. Secondary outcomes will be assessed in all patients irrespective of time of treatment. All analyses will be conducted on an intention-to-treat basis. CONCLUSIONS This IPD meta-analysis will examine important clinical questions about the effects of anti-fibrinolytic treatment in patients with intracranial haemorrhage that cannot be answered using aggregate data. With IPD we can examine how effects vary by time to treatment, bleeding severity, and age, to gain better understanding of the balance of benefit and harms on which to base recommendations for practice.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - David Prieto-Merino
- Catholic University of Murcia, Campus de los Jeronimos, Murcia, Spain.,London School of Hygiene & Tropical Medicine, London, UK
| | - Nikola Sprigg
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Abda Mahmood
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Bath
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Zhe Kang Law
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Katie Flaherty
- Stroke, Division of Clinical Neurosciences, Faculty of Medicine & Health Sciences, Clinical Sciences Building, Nottingham City Hospital, Nottingham, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Post R, Germans MR, Boogaarts HD, Ferreira Dias Xavier B, Van den Berg R, Coert BA, Vandertop WP, Verbaan D. Short-term tranexamic acid treatment reduces in-hospital mortality in aneurysmal sub-arachnoid hemorrhage: A multicenter comparison study. PLoS One 2019; 14:e0211868. [PMID: 30730957 PMCID: PMC6366882 DOI: 10.1371/journal.pone.0211868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Recurrent bleeding is one of the major causes of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Antifibrinolytic therapy is known to reduce recurrent bleeding, however, its beneficial effect on outcome remains unclear. The effect of treatment with tranexamic acid (TXA) until aneurysm treatment on clinical outcome is evaluated. Methods Patients with an aSAH from two high-volume tertiary referral treatment centers in the Netherlands, Academic Medical Center (AMC) and Radboud University Medical Center (RUMC), between January 2012 and December 2015 were included. Patients were classified into one of two groups; standard treatment or TXA treatment. Demographic and clinical characteristics, in-hospital complications and clinical outcome were compared between the two groups. Multivariate logistic regression was used to adjust for the influence of treatment center and baseline differences. Results Standard treatment was given in 509 patients, and 119 patients received additional TXA therapy before aneurysm occlusion. Patients treated with TXA did not experience less recurrent bleeding adjusted or unadjusted for treatment center (adjusted odds ratio [aOR] 0.80, 95% confidence interval [95% CI]: 0.37–1.73). In-hospital mortality, was significantly lower in the TXA group than the standard care group (adjusted OR [aOR] 0.42, 95% CI: 0.20–0.85). Poor outcome (mRS 4–6) assessed after six months was not different between treatment groups (aOR 1.05, 95% CI: 0.64–1.74). Conclusions Pooled data from two high-volume treatment centers did not show improved clinical outcome after additional TXA treatment in aSAH patients. However, TXA treatment was associated with a decrease in mortality.
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Affiliation(s)
- R. Post
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - M. R. Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zürich, Zürich, Switzerland
| | - H. D. Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - R. Van den Berg
- Department of Radiology, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - B. A. Coert
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - W. P. Vandertop
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - D. Verbaan
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
- * E-mail:
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He Q, Zhou Y, Liu C, Zhang X, Huang N, Wang F, Liu G, Cheng Y, Xie Z. Thromboelastography with Platelet Mapping Detects Platelet Dysfunction in Patients with Aneurysmal Subarachnoid Hemorrhage with Rebleeding. Neuropsychiatr Dis Treat 2019; 15:3443-3451. [PMID: 31908459 PMCID: PMC6924584 DOI: 10.2147/ndt.s229284] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) has high rates of disability and mortality, and aneurysm rebleeding is associated with poor functional outcomes. Thrombelastography with platelet mapping (TEG-PM) measures platelet function; however, it has not yet been researched in aSAH. We aimed to use TEG-PM to detect changes in platelet function in patients with aSAH and the difference in patients with and without rebleeding. METHODS We retrospectively included patients with aSAH who underwent a TEG-PM test on admission. Rebleeding was diagnosed according to clinical and imaging data. TEG-PM data of patients with unruptured intracranial aneurysms (UIA) were also obtained as controls. Univariate and multivariate logistic regression models were performed to investigate the relationship between the platelet function and rebleeding. RESULTS A total of 245 aSAH patients and 32 UIA patients were included in our study. Compared with controls, patients with aSAH demonstrated higher arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition of platelet function (P<0.05). Among them, 27 patients with Hunt-Hess grade IV or V were classified as the severe SAH group. There was a significant correlation between the severe SAH group and the degree of pathway inhibition (P<0.05). Furthermore, AA (Spearman's r=0.264, P<0.001) and ADP (Spearman's r=0.183, P=0.004) inhibition were elevated in Hunt-Hess grade-dependent manners. The AA (Spearman's r=0.169, P=0.008) and ADP (Spearman's r=0.233, P<0.001) inhibition were also significantly correlated with Fisher grade. Thirty-five patients (14.3%) suffered rebleeding. Rebleeding was significantly correlated with systolic blood pressure (P=0.011), diastolic blood pressure (P=0.008), Hunt-Hess grade (P=0.034), Fisher grade (P=0.015), AA inhibition (P<0.001), and ADP inhibition (P<0.001). Multivariate logistic regression analysis model revealed that both AA (P=0.037) and ADP inhibition (P=0.008) were independent determinants for rebleeding. CONCLUSION TEG-PM may assess platelet dysfunction in patients with aSAH, and the diminished platelet response to ADP and AA may be associated with rebleeding. These findings deserve further investigation.
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Affiliation(s)
- Qiuguang He
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - You Zhou
- Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chang Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiang Zhang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Ning Huang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Feng Wang
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Guodong Liu
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yuan Cheng
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zongyi Xie
- Department of Neurosurgery, The Second Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Abstract
A warning leak is a curious phenomenon attributed to cerebral aneurysms. Once the leak occurs, it has been postulated it could lead to a more catastrophic rebleeding. The designation "warning leak" trickled into neurosurgery vocabulary as early as the 1950s. The phenomenon has been poorly understood and characterized, but its presence spurs emergency physicians and neurointensivists to take action to secure the aneurysm. Rapid treatment of a recently discovered aneurysm is now commonplace, but it has not always been so. Antifibrinolytic agents spawned particular interest in the late 1970s, when many neurosurgeons postponed surgery after a recent hemorrhage. This historical vignette reviews the early views on aneurysmal rupture, rerupture, and the role of fibrinolysis.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Maagaard M, Karlsson WK, Ovesen C, Gluud C, Jakobsen JC. Interventions for altering blood pressure in people with acute subarachnoid haemorrhage. Hippokratia 2018. [DOI: 10.1002/14651858.cd013096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mathias Maagaard
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - William K Karlsson
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
- Herlev Hospital; Department of Neurology; Herlev Ringvej 75 Copenhagen Denmark 2730
| | - Christian Ovesen
- Bispebjerg Hospital, University of Copenhagen; Department of Neurology; Bispebjerg Bakke 23 Copenhagen NV Denmark 2400
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology 2018; 128:657-670. [PMID: 29200009 PMCID: PMC5811331 DOI: 10.1097/aln.0000000000001997] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Ker K, Prieto-Merino D, Sprigg N, Mahmood A, Bath P, Kang Law Z, Flaherty K, Roberts I. The effectiveness and safety of antifibrinolytics in patients with acute intracranial haemorrhage: statistical analysis plan for an individual patient data meta-analysis. Wellcome Open Res 2018; 2:120. [DOI: 10.12688/wellcomeopenres.13262.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction: The Antifibrinolytic Trialists Collaboration aims to increase knowledge about the effectiveness and safety of antifibrinolytic treatment by conducting individual patient data (IPD) meta-analyses of randomised trials. This article presents the statistical analysis plan for an IPD meta-analysis of the effects of antifibrinolytics for acute intracranial haemorrhage. Methods: The protocol for the IPD meta-analysis has been registered with PROSPERO (CRD42016052155). We will conduct an individual patient data meta-analysis of randomised controlled trials with 1000 patients or more assessing the effects of antifibrinolytics in acute intracranial haemorrhage. We will assess the effect on two co-primary outcomes: 1) Death in hospital within 30 days of randomisation, and 2) Death or dependency at final follow-up within 90 days of randomisation. The co-primary outcomes will be limited to patients treated within three hours of injury or stroke onset. We will report treatment effects using odds ratios and 95% confidence intervals. We use logistic regression models to examine how the effect of antifibrinolytics vary by time to treatment, severity of intracranial bleeding, and age. We will also examine the effect of antifibrinolytics on secondary outcomes including death, dependency, vascular occlusive events, seizures, and neurological outcomes. Secondary outcomes will be assessed in all patients irrespective of time of treatment. All analyses will be conducted on an intention-to-treat basis. Conclusions: This IPD meta-analysis will examine important clinical questions about the effects of antifibrinolytic treatment in patients with intracranial haemorrhage that cannot be answered using aggregate data. With IPD we can examine how effects vary by time to treatment, bleeding severity, and age, to gain better understanding of the balance of benefit and harms on which to base recommendations for practice.
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Dineen RA, Pszczolkowski S, Flaherty K, Law ZK, Morgan PS, Roberts I, Werring DJ, Al-Shahi Salman R, England T, Bath PM, Sprigg N. Does tranexamic acid lead to changes in MRI measures of brain tissue health in patients with spontaneous intracerebral haemorrhage? Protocol for a MRI substudy nested within the double-blind randomised controlled TICH-2 trial. BMJ Open 2018; 8:e019930. [PMID: 29431141 PMCID: PMC5879748 DOI: 10.1136/bmjopen-2017-019930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/28/2017] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To test whether administration of the antifibrinolytic drug tranexamic acid (TXA) in patients with spontaneous intracerebral haemorrhage (SICH) leads to increased prevalence of diffusion-weighted MRI-defined hyperintense ischaemic lesions (primary hypothesis) or reduced perihaematomal oedema volume, perihaematomal diffusion restriction and residual MRI-defined SICH-related tissue damage (secondary hypotheses). DESIGN MRI substudy nested within the double-blind randomised controlled Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH)-2 trial (ISRCTN93732214). SETTING International multicentre hospital-based study. PARTICIPANTS Eligible adults consented and randomised in the TICH-2 trial who were also able to undergo MRI scanning. To address the primary hypothesis, a sample size of n=280 will allow detection of a 10% relative increase in prevalence of diffusion-weighted imaging (DWI) hyperintense lesions in the TXA group with 5% significance, 80% power and 5% imaging data rejection. INTERVENTIONS TICH-2 MRI substudy participants will undergo MRI scanning using a standardised protocol at day ~5 and day ~90 after randomisation. Clinical assessments, randomisation to TXA or placebo and participant follow-up will be performed as per the TICH-2 trial protocol. CONCLUSION The TICH-2 MRI substudy will test whether TXA increases the incidence of new DWI-defined ischaemic lesions or reduces perihaematomal oedema or final ICH lesion volume in the context of SICH. ETHICS AND DISSEMINATION The TICH-2 trial obtained ethical approval from East Midlands - Nottingham 2 Research Ethics Committee (12/EM/0369) and an amendment to allow the TICH-2 MRI sub study was approved in April 2015 (amendment number SA02/15). All findings will be published in peer-reviewed journals. The primary outcome results will also be presented at a relevant scientific meeting. TRIAL REGISTRATION NUMBER ISRCTN93732214; Pre-results.
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Affiliation(s)
- Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Stefan Pszczolkowski
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zhe K Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Paul S Morgan
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK
- Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, London, UK
| | | | - Tim England
- Vascular Medicine, Division of Medical Sciences and GEM, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120:988-998. [PMID: 29661416 DOI: 10.1016/j.bja.2017.11.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 01/04/2023] Open
Abstract
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
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Affiliation(s)
- A Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - M Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
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[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]. Med Klin Intensivmed Notfmed 2018; 114:642-649. [PMID: 29368267 DOI: 10.1007/s00063-018-0402-5] [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: 09/13/2017] [Revised: 11/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. OBJECTIVES The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. METHODS Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). RESULTS TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. CONCLUSION Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.
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Flaherty K, Bath PM, Dineen R, Law Z, Scutt P, Pocock S, Sprigg N. Statistical analysis plan for the 'Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage' (TICH-2) trial. Trials 2017; 18:607. [PMID: 29262841 PMCID: PMC5738041 DOI: 10.1186/s13063-017-2341-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/09/2017] [Indexed: 11/10/2022] Open
Abstract
RATIONALE Aside from blood pressure lowering, treatment options for intracerebral haemorrhage remain limited and a proportion of patients will undergo early haematoma expansion with resultant significant morbidity and mortality. Tranexamic acid (TXA), an anti-fibrinolytic drug, has been shown to significantly reduce mortality in patients, who are bleeding following trauma, when given rapidly. TICH-2 is testing whether TXA is effective at improving outcome in spontaneous intracerebral haemorrhage (SICH). METHODS AND DESIGN TICH-2 is a pragmatic, phase III, prospective, double-blind, randomised placebo-controlled trial. Two thousand adult (aged ≥ 18 years) patients with an acute SICH, within 8 h of stroke onset, will be randomised to receive TXA or the placebo control. The primary outcome is ordinal shift of modified Rankin Scale score at day 90. Analyses will be performed using intention-to-treat. RESULTS This paper and its attached appendices describe the statistical analysis plan (SAP) for the trial and were developed and published prior to database lock and unblinding to treatment allocation. The SAP includes details of analyses to be undertaken and unpopulated tables which will be reported in the primary and key secondary publications. The database will be locked in early 2018, ready for publication of the results later in the same year. DISCUSSION The SAP details the analyses that will be done to avoid bias arising from prior knowledge of the study findings. The trial will determine whether TXA can improve outcome after SICH, which currently has no definitive therapy. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN93732214 . Registered on 17 January 2013.
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Affiliation(s)
- Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Robert Dineen
- Imaging Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zhe Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
| | - on behalf of the TICH-2 investigators
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB UK
- Imaging Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
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Baharoglu MI, Brand A, Koopman MM, Vermeulen M, Roos YB. Acute Management of Hemostasis in Patients With Neurological Injury. Transfus Med Rev 2017; 31:236-244. [DOI: 10.1016/j.tmrv.2017.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 01/28/2023]
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Discovery of a ROCK inhibitor, FPND, which prevents cerebral hemorrhage through maintaining vascular integrity by interference with VE-cadherin. Cell Death Discov 2017; 3:17051. [PMID: 28845297 PMCID: PMC5563523 DOI: 10.1038/cddiscovery.2017.51] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 02/07/2023] Open
Abstract
Hemorrhagic stroke occurs when a weakened vessel ruptures and bleeds into the surrounding brain, leading to high rates of death and disability worldwide. A series of complex pathophysiological cascades contribute to the risk of hemorrhagic stroke, and no therapies have proven effective to prevent hemorrhagic stroke. Stabilization of vascular integrity has been considered as a potential therapeutic target for hemorrhagic stroke. ROCKs, which belong to the serine/threonine protein kinase family and participate in the organization of actin cytoskeleton, have become attractive targets for the treatment of strokes. In this study, in vitro enzyme-based assays revealed that a new compound (FPND) with a novel scaffold identified by docking-based virtual screening could inhibit ROCK1 specifically at low micromolar concentration. Molecular modeling showed that FPND preferentially interacted with ROCK1, and the difference between the binding affinity of FPND toward ROCK1 and ROCK2 primarily resulted from non-polar contributions. Furthermore, FPND significantly prevented statin-induced cerebral hemorrhage in a zebrafish model. In addition, in vitro studies using the xCELLigence RTCA system, immunofluorescence and western blotting revealed that FPND prevented statin-induced cerebral hemorrhage by enhancing endothelial cell–cell junctions through inhibiting the ROCK-mediated VE-cadherin signaling pathway. As indicated by the extremely low toxicity of FPND against mice, it is safe and can potentially prevent vascular integrity loss-related diseases, such as hemorrhagic stroke.
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A nested mechanistic sub-study into the effect of tranexamic acid versus placebo on intracranial haemorrhage and cerebral ischaemia in isolated traumatic brain injury: study protocol for a randomised controlled trial (CRASH-3 Trial Intracranial Bleeding Mechanistic Sub-Study [CRASH-3 IBMS]). Trials 2017; 18:330. [PMID: 28716153 PMCID: PMC5513059 DOI: 10.1186/s13063-017-2073-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/28/2017] [Indexed: 12/31/2022] Open
Abstract
Background Tranexamic acid prevents blood clots from breaking down and reduces bleeding. However, it is uncertain whether tranexamic acid is effective in traumatic brain injury. The CRASH-3 trial is a randomised controlled trial that will examine the effect of tranexamic acid (versus placebo) on death and disability in 13,000 patients with traumatic brain injury. The CRASH-3 trial hypothesizes that tranexamic acid will reduce intracranial haemorrhage, which will reduce the risk of death. Although it is possible that tranexamic acid will reduce intracranial bleeding, there is also a potential for harm. In particular, tranexamic acid may increase the risk of cerebral thrombosis and ischaemia. The protocol detailed here is for a mechanistic sub-study nested within the CRASH-3 trial. This mechanistic sub-study aims to examine the effect of tranexamic acid (versus placebo) on intracranial bleeding and cerebral ischaemia. Methods The CRASH-3 Intracranial Bleeding Mechanistic Sub-Study (CRASH-3 IBMS) is nested within a prospective, double-blind, multi-centre, parallel-arm randomised trial called the CRASH-3 trial. The CRASH-3 IBMS will be conducted in a cohort of approximately 1000 isolated traumatic brain injury patients enrolled in the CRASH-3 trial. In the CRASH-3 IBMS, brain scans acquired before and after randomisation are examined, using validated methods, for evidence of intracranial bleeding and cerebral ischaemia. The primary outcome is the total volume of intracranial bleeding measured on computed tomography after randomisation, adjusting for baseline bleeding volume. Secondary outcomes include progression of intracranial haemorrhage (from pre- to post-randomisation scans), new intracranial haemorrhage (seen on post- but not pre-randomisation scans), intracranial haemorrhage following neurosurgery, and new focal ischaemic lesions (seen on post-but not pre-randomisation scans). A linear regression model will examine whether receipt of the trial treatment can predict haemorrhage volume. Bleeding volumes and new ischaemic lesions will be compared across treatment groups using relative risks and 95% confidence intervals. Discussion The CRASH-3 IBMS will provide an insight into the mechanism of action of tranexamic acid in traumatic brain injury, as well as information about the risks and benefits. Evidence from this trial could inform the management of patients with traumatic brain injury. Trial registration The CRASH-3 trial was prospectively registered and the CRASH-3 IBMS is an addition to the original protocol registered at the International Standard Randomised Controlled Trials registry (ISRCTN15088122) 19 July 2011, and ClinicalTrials.gov on 25 July 2011 (NCT01402882). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2073-6) contains supplementary material, which is available to authorized users.
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Zhou ZF, Zhang FJ, Huo YF, Yu YX, Yu LN, Sun K, Sun LH, Xing XF, Yan M. Intraoperative tranexamic acid is associated with postoperative stroke in patients undergoing cardiac surgery. PLoS One 2017; 12:e0177011. [PMID: 28552944 PMCID: PMC5446127 DOI: 10.1371/journal.pone.0177011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/20/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Stroke is a devastating and potentially preventable complication of cardiac surgery. Tranexamic acid (TXA) is a commonly antifibrinolytic agent in cardiac surgeries with cardiopulmonary bypass (CPB), however, there is concern that it might increase incidence of stroke after cardiac surgery. In this retrospective study, we investigated whether TXA usage could increase postoperative stroke in cardiac surgery. METHODS A retrospective study was conducted from January 1, 2010, to December 31, 2015, in 2,016 patients undergoing cardiac surgery, 664 patients received intravenous TXA infusion and 1,352 patients did not receive any antifibrinolytic agent. Univariate and propensity-weighted multivariate regression analysis were applied for data analysis. RESULTS Intraoperative TXA administration was associated with postoperative stroke (1.7% vs. 0.5%; adjusted OR, 4.11; 95% CI, 1.33 to 12.71; p = 0.014) and coma (adjusted OR, 2.77; 95% CI, 1.06 to 7.26; p = 0.038) in cardiac surgery. As subtype analysis was performed, TXA administration was still associated with postoperative stroke (1.7% vs. 0.3%; adjusted OR, 5.78; 95% CI, 1.34 to 27.89; p = 0.018) in patients undergoing valve surgery or multi-valve surgery only, but was not associated with postoperative stroke (1.7% vs. 1.3%; adjusted OR, 5.21; 95% CI, 0.27 to 101.17; p = 0.276) in patients undergoing CABG surgery only. However, TXA administration was not associated with postoperative mortality (adjusted OR, 1.31; 95% CI, 0.56 to 3.71; p = 0.451), seizure (adjusted OR, 1.13; 95% CI, 0.42 to 3.04; p = 0.816), continuous renal replacement therapy (adjusted OR, 1.36; 95% CI, 0.56 to 3.28; p = 0.495) and resternotomy for postoperative bleeding (adjusted OR, 1.55; 95% CI, 0.55 to 4.30; p = 0.405). No difference was found in postoperative ventilation time (adjusted B, -1.45; SE, 2.33; p = 0.535), length of intensive care unit stay (adjusted B, -0.12; SE, 0.25; p = 0.633) and length of hospital stay (adjusted B, 0.48; SE, 0.58; p = 0.408). CONCLUSIONS Based on the 5-year experience of TXA administration in cardiac surgery with CPB, we found that postoperative stroke was associated with intraoperative TXA administration in patients undergoing cardiac surgery, especially in those undergoing valve surgeries only. This study may suggest that TXA should be administrated according to clear indications after evaluating the bleeding risk in patients undergoing cardiac surgery, especially in those with high stroke risk.
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Affiliation(s)
- Zhen-feng Zhou
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng-jiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | | | - Yun-xian Yu
- Department of Epidemiology and Health Statistics, School of Public Health, Zhejiang University, Hangzhou, China
| | - Li-na Yu
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li-hong Sun
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Xiu-fang Xing
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Pabinger I, Fries D, Schöchl H, Streif W, Toller W. Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis. Wien Klin Wochenschr 2017; 129:303-316. [PMID: 28432428 PMCID: PMC5429347 DOI: 10.1007/s00508-017-1194-y] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/14/2017] [Indexed: 02/08/2023]
Abstract
Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i. e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e. g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Department of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria.
| | - Dietmar Fries
- Department of General and Surgical Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Accident Hospital Salzburg, Salzburg, Austria
- Academic Teaching Hospital, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Werner Streif
- Department of Children and Adolescents Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, Graz, Austria
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a neurological emergency with high risk of neurological decline and death. Although the presentation of a thunderclap headache or the worst headache of a patient's life easily triggers the evaluation for SAH, subtle presentations are still missed. The gold standard for diagnostic evaluation of SAH remains noncontrast head computed tomography (CT) followed by lumbar puncture if the CT is negative for SAH. Management of patients with SAH follows standard resuscitation of critically ill patients with the emphasis on reducing risks of rebleeding and avoiding secondary brain injuries.
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Affiliation(s)
- Michael K Abraham
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| | - Wan-Tsu Wendy Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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