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Yeager CE, Garg RK. Advances and Future Trends in the Diagnosis and Management of Intracerebral Hemorrhage. Neurol Clin 2024; 42:689-703. [PMID: 38937036 DOI: 10.1016/j.ncl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Spontaneous intracerebral hemorrhage accounts for approximately 10% to 15% of all strokes in the United States and remains one of the deadliest. Of concern is the increasing prevalence, especially in younger populations. This article reviews the following: epidemiology, risk factors, outcomes, imaging findings, medical management, and updates to surgical management.
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Affiliation(s)
- Christine E Yeager
- Division of Critical Care Neurology, Rush University Medical Center, 1725 W Harrison Street, Suite 1106, Chicago, IL, USA.
| | - Rajeev K Garg
- Division of Critical Care Neurology, Section of Cognitive Neurosciences, Rush University Medical Center, 1725 W Harrison Street, Suite 1106, Chicago, IL, USA
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Hirata K, Fujita K, Ishikawa E, Matsumaru Y. The efficacy and safety of the internal medication therapy of the triple drugs for chronic subdural hematoma: Retrospective analysis. Clin Neurol Neurosurg 2024; 244:108434. [PMID: 39018994 DOI: 10.1016/j.clineuro.2024.108434] [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: 05/27/2024] [Revised: 07/04/2024] [Accepted: 07/04/2024] [Indexed: 07/19/2024]
Abstract
The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis.
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Affiliation(s)
- Koji Hirata
- Department of Neurosurgery, Ibaraki Seinan Medical Center Hospital, Sashima, Ibaraki, Japan; Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Keishi Fujita
- Department of Neurosurgery, Ibaraki Seinan Medical Center Hospital, Sashima, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Sieh L, Peasley E, Mao E, Mitchell A, Heinonen G, Ghoshal S, Agarwal S, Park S, Connolly ES, Claassen J, Moore EE, Hansen K, Hod EA, Francis RO, Roh DJ. Admission Viscoelastic Hemostatic Assay Parameters Predict Poor Long-Term Intracerebral Hemorrhage Outcomes. Neurocrit Care 2024:10.1007/s12028-024-02051-w. [PMID: 38955933 DOI: 10.1007/s12028-024-02051-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Viscoelastic hemostatic assays (VHAs) provide more comprehensive assessments of coagulation compared with conventional coagulation assays. Although VHAs have enabled guided hemorrhage control therapies, improving clinical outcomes in life-threatening hemorrhage, the role of VHAs in intracerebral hemorrhage (ICH) is unclear. If VHAs can identify coagulation abnormalities relevant for ICH outcomes, this would support the need to investigate the role of VHAs in ICH treatment paradigms. Thus, we investigated whether VHA assessments of coagulation relate to long-term ICH outcomes. METHODS Patients with spontaneous ICH enrolled into a single-center cohort study receiving admission Rotational Thromboelastometry (ROTEM) VHA testing between 2013 and 2020 were assessed. Patients with previous anticoagulant use or coagulopathy on conventional coagulation assays were excluded. Primary ROTEM exposure variables were coagulation kinetics and clot strength assessments. Poor long-term outcome was defined as modified Rankin Scale ≥ 4 at 6 months. Logistic regression analyses assessed associations of ROTEM parameters with clinical outcomes after adjusting for ICH severity and hemoglobin concentration. RESULTS Of 44 patients analyzed, the mean age was 64 years, 57% were female, and the median ICH volume was 23 mL. Poor 6-month outcome was seen in 64% of patients. In our multivariable regression models, slower, prolonged coagulation kinetics (adjusted odds ratio for every second increase in clot formation time 1.04, 95% confidence interval 1.00-1.09, p = 0.04) and weaker clot strength (adjusted odds ratio for every millimeter increase of maximum clot firmness 0.84, 95% confidence interval 0.71-0.99, p = 0.03) were separately associated with poor long-term outcomes. CONCLUSIONS Slower, prolonged coagulation kinetics and weaker clot strength on admission VHA ROTEM testing, not attributable to anticoagulant use, were associated with poor long-term outcomes after ICH. Further work is needed to clarify the generalizability and the underlying mechanisms of these VHA findings to assess whether VHA-guided treatments should be incorporated into ICH care.
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Affiliation(s)
- Laura Sieh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Emma Peasley
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Eric Mao
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Amanda Mitchell
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Gregory Heinonen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Shivani Ghoshal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Kirk Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO, USA
| | - Eldad A Hod
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Richard O Francis
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - David J Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, 177 Fort Washington Ave, New York, NY, 10032, USA.
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Yang WS, Liu JY, Shen YQ, Xie XF, Zhang SQ, Liu FY, Yu JL, Ma YB, Xiao ZS, Duan HW, Li Q, Chen SX, Xie P. Quantitative imaging for predicting hematoma expansion in intracerebral hemorrhage: A multimodel comparison. J Stroke Cerebrovasc Dis 2024; 33:107731. [PMID: 38657831 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/21/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Several studies report that radiomics provides additional information for predicting hematoma expansion in intracerebral hemorrhage (ICH). However, the comparison of diagnostic performance of radiomics for predicting revised hematoma expansion (RHE) remains unclear. METHODS The cohort comprised 312 consecutive patients with ICH. A total of 1106 radiomics features from seven categories were extracted using Python software. Support vector machines achieved the best performance in both the training and validation datasets. Clinical factors models were constructed to predict RHE. Receiver operating characteristic curve analysis was used to assess the abilities of non-contrast computed tomography (NCCT) signs, radiomics features, and combined models to predict RHE. RESULTS We finally selected the top 21 features for predicting RHE. After univariate analysis, 4 clinical factors and 5 NCCT signs were selected for inclusion in the prediction models. In the training and validation dataset, radiomics features had a higher predictive value for RHE (AUC = 0.83) than a single NCCT sign and expansion-prone hematoma. The combined prediction model including radiomics features, clinical factors, and NCCT signs achieved higher predictive performances for RHE (AUC = 0.88) than other combined models. CONCLUSIONS NCCT radiomics features have a good degree of discrimination for predicting RHE in ICH patients. Combined prediction models that include quantitative imaging significantly improve the prediction of RHE, which may assist in the risk stratification of ICH patients for anti-expansion treatments.
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Affiliation(s)
- Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Jia-Yang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Yi-Qing Shen
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Xiong-Fei Xie
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Shu-Qiang Zhang
- Department of Radiology, Chongqing University Fuling Hospital, Chongqing 408000, China.
| | - Fang-Yu Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Jia-Lun Yu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Yong-Bo Ma
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Zhong-Song Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Hao-Wei Duan
- College of computer and information science, Southwest University, Chongqing 400715, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Shan-Xiong Chen
- College of computer and information science, Southwest University, Chongqing 400715, China.
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Mutimer CA, Yassi N, Wu TY. Blood Pressure Management in Intracerebral Haemorrhage: when, how much, and for how long? Curr Neurol Neurosci Rep 2024; 24:181-189. [PMID: 38780706 PMCID: PMC11199276 DOI: 10.1007/s11910-024-01341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW When compared to ischaemic stroke, there have been limited advances in acute management of intracerebral haemorrhage. Blood pressure control in the acute period is an intervention commonly implemented and recommended in guidelines, as elevated systolic blood pressure is common and associated with haematoma expansion, poor functional outcomes, and mortality. This review addresses the uncertainty around the optimal blood pressure intervention, specifically timing and length of intervention, intensity of blood pressure reduction and agent used. RECENT FINDINGS Recent pivotal trials have shown that acute blood pressure intervention, to a systolic target of 140mmHg, does appear to be beneficial in ICH, particularly when bundled with other therapies such as neurosurgery in selected cases, access to critical care units, blood glucose control, temperature management and reversal of coagulopathy. Systolic blood pressure should be lowered acutely in intracerebral haemorrhage to a target of approximately 140mmHg, and that this intervention is generally safe in the ICH population.
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Affiliation(s)
- Chloe A Mutimer
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia.
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024; 403:2820-2836. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Menditto VG, Rossetti G, Sampaolesi M, Buzzo M, Pomponio G. Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department. J Clin Med 2024; 13:3669. [PMID: 38999235 PMCID: PMC11242576 DOI: 10.3390/jcm13133669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.
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Affiliation(s)
- Vincenzo G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giulia Rossetti
- Internal Medicine, Santa Croce Hospital AST1 Pesaro Urbino, 61032 Fano, Italy
| | - Mattia Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Marta Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanni Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Siepen BM, Polymeris A, Shoamanesh A, Connolly S, Steiner T, Poli S, Lemmens R, Goeldlin MB, Müller M, Branca M, Rauch J, Meinel T, Kaesmacher J, Z'Graggen W, Arnold M, Fischer U, Peters N, Engelter ST, Lyrer P, Seiffge D. Andexanet alfa versus non-specific treatments for intracerebral hemorrhage in patients taking factor Xa inhibitors - Individual patient data analysis of ANNEXA-4 and TICH-NOAC. Int J Stroke 2024; 19:506-514. [PMID: 38264861 DOI: 10.1177/17474930241230209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Data comparing the specific reversal agent andexanet alfa with non-specific treatments in patients with non-traumatic intracerebral hemorrhage (ICH) associated with factor-Xa inhibitor (FXaI) use are scarce. AIM The study aimed to determine the association between the use of andexanet alfa compared with non-specific treatments with the rate of hematoma expansion and thromboembolic complications in patients with FXaI-associated ICH. METHODS We performed an individual patient data analysis combining two independent, prospective studies: ANNEXA-4 (180 patients receiving andexanet alfa, NCT02329327) and TICH-NOAC (63 patients receiving tranexamic acid or placebo ± prothrombin complex concentrate, NCT02866838). The primary efficacy outcome was hematoma expansion on follow-up imaging. The primary safety outcome was any thromboembolic complication (ischemic stroke, myocardial infarction, pulmonary embolism, or deep vein thrombosis) at 30 days. We used binary logistic regression models adjusted for baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively. RESULTS Among 243 participants included, the median age was 80 (IQR 75-84) years, baseline hematoma volume was 9.1 (IQR 3.4-21) mL and anti-Xa activity 118 (IQR 78-222) ng/mL. Times from last FXaI intake and symptom onset to treatment were 11 (IQR 7-16) and 4.7 (IQR 3.0-7.6) h, respectively. Overall, 50 patients (22%) experienced hematoma expansion (ANNEXA-4: n=24 (14%); TICH-NOAC: n=26 (41%)). After adjusting for pre-specified confounders (baseline hematoma volume, age, calibrated anti-Xa activity, times from last intake of FXaI, and symptom onset to treatment, respectively), treatment with andexanet alfa was independently associated with decreased odds for hematoma expansion (aOR 0.33, 95% CI 0.13-0.80, p = 0.015). Overall, 26 patients (11%) had any thromboembolic complication within 30 days (ANNEXA-4: n=20 (11%); TICH-NOAC: n=6 (10%)). There was no association between any thromboembolic complication and treatment with andexanet alfa (aOR 0.70, 95% CI 0.16-3.12, p = 0.641). CONCLUSION The use of andexanet alfa compared to any other non-specific treatment strategy was associated with decreased odds for hematoma expansion, without increased odds for thromboembolic complications.
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Affiliation(s)
- Bernhard M Siepen
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Alexandros Polymeris
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Thorsten Steiner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Neurology, Höechst Hospital Frankfurt, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tuebingen, Tübingen, Germany
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium
| | - Martina B Goeldlin
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Madlaine Müller
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | | | - Janis Rauch
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Werner Z'Graggen
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology and Neurorehabilitation, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
- Stroke Center Hirslanden, Klinik Hirslanden Zurich, Zurich, Switzerland
| | - Stefan T Engelter
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology and Neurorehabilitation, University of Basel, Basel, Switzerland
- University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
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9
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Gabriele F, Foschi M, Conversi F, Ciuffini D, De Santis F, Orlandi B, De Santis F, Ornello R, Sacco S. Epidemiology and outcomes of intracerebral hemorrhage associated with oral anticoagulation over 10 years in a population-based stroke registry. Int J Stroke 2024; 19:515-525. [PMID: 37997897 DOI: 10.1177/17474930231218594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Recent years have seen a change in the use of anticoagulants in the general population due to the availability of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists (VKAs) and increased detection of atrial fibrillation. It is important to have updated epidemiological data to understand how this change is impacting on the occurrence and outcome of intracerebral hemorrhage (ICH). PATIENTS AND METHODS Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Oral anticoagulants (OAC)-related ICH was defined as an ICH occurring within 48 h from the intake of DOAC or VKAs, regardless of the measured international normalized ratio on hospital admission. RESULTS We included 748 first-ever ICH, of whom 108 (14.4%) were OAC-related. Specifically, 75 (69.4%) ICHs occurred on VKA and 33 (30.6%) on DOAC. The incidence of oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) was stable over time (p = 0.226). Among OAC-ICHs, we observed an increase in the overall incidence of DOAC-ICH (p for trend < 0.001) which overcome that of VKA-ICH in 2020 (incidence rate ratio (IRR) 4.71, 95% confidence interval (CI): 1.22-33.54; p = 0.022). Patients with OAC-ICH showed higher 30-day case fatality rates than those with non-OAC-ICH (48.1% vs 34.1%; p = 0.007). CONCLUSION No changes over time were detected in the incidence of OAC-ICH, but throughout the study period, there was a change in OAC-ICH from mostly VKA-related to mostly DOAC-related. Mortality in patients with OAC-ICH was higher than in patients with non-OAC-ICH.
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Affiliation(s)
- Francesca Gabriele
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Conversi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Davide Ciuffini
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federica De Santis
- Department of Neurology and Stroke Unit of Avezzano-Sulmona, ASL 1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Berardino Orlandi
- Department of Neurology and Stroke Unit of Avezzano-Sulmona, ASL 1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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10
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Seiffge DJ, Anderson CS. Treatment for intracerebral hemorrhage: Dawn of a new era. Int J Stroke 2024; 19:482-489. [PMID: 38803115 DOI: 10.1177/17474930241250259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Intracerebral hemorrhage (ICH) is a devastating disease, causing high rates of death, disability, and suffering across the world. For decades, its treatment has been shrouded by the lack of reliable evidence, and consequently, the presumption that an effective treatment is unlikely to be found. Neutral results arising from several major randomized controlled trials had established a negative spirit within and outside the stroke community. Frustration among researchers and a sense of nihilism in clinicians has created the general perception that patients presenting with ICH have a poor prognosis irrespective of them receiving any form of active management. All this changed in 2023 with the positive results on the primary outcome in randomized controlled trials showing treatment benefits for a hyperacute care bundle approach (INTERACT3), early minimal invasive hematoma evacuation (ENRICH), and use of factor Xa-inhibitor anticoagulation reversal with andexanet alfa (ANNEXa-I). These advances have now been extended in 2024 by confirmation that intensive blood pressure lowering initiated within the first few hours of the onset of symptoms can substantially improve outcome in ICH (INTERACT4) and that decompressive hemicraniectomy is a viable treatment strategy in patients with large deep ICH (SWITCH). This evidence will spearhead a change in the perception of ICH, to revolutionize the care of these patients to ultimately improve their outcomes. We review these and other recent developments in the hyperacute management of ICH. We summarize the results of randomized controlled trials and discuss related original research papers published in this issue of the International Journal of Stroke. These exciting advances demonstrate how we are now at the dawn of a new, exciting, and brighter era of ICH management.
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Affiliation(s)
- David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Institute for Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China
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11
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Ferguson E, Lun R, Rosenberg H. Just the facts: management of thrombolytic complications in acute stroke care in the emergency department. CAN J EMERG MED 2024; 26:386-388. [PMID: 38796809 DOI: 10.1007/s43678-024-00713-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Emma Ferguson
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, ON, Canada.
| | - Ronda Lun
- Department of Vascular Neurology, Stanford Hospital, Palo Alto, CA, USA
| | - Hans Rosenberg
- Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, ON, Canada
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12
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Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol 2024; 23:577-587. [PMID: 38648814 DOI: 10.1016/s1474-4422(24)00128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. METHODS STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18-30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. FINDINGS Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55-77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI -0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). INTERPRETATION Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. FUNDING Australian Government Medical Research Future Fund.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Viet Nam
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Phuc Dang Duc
- Stroke Department, 103 Military Hospital, Hanoi, Viet Nam
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, and School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, VIC, Australia
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Yanchao, Taiwan
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Emma L Harrison
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Devlin
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Dennis Cordato
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Vincent Thijs
- The Florey, Stroke Theme, Heidelberg, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia; Department of Medicine, University of Melbourne, Heidelberg, VIC, Australia
| | - Lauren M Sanders
- Department of Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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13
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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14
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Song L, Zhou H, Cheng J, Guo W, Ye Y, Wang R, Chen J, Xiong H, Zhang J, Tang D, Zou L, Kuang L, Qiu X, Guo T. Is the frequency of imaging markers still a predictor for revised intracerebral hemorrhage expansion? Eur Stroke J 2024; 9:376-382. [PMID: 38234113 DOI: 10.1177/23969873241227321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Frequency of imaging markers (FIM) has been described as a novel predictor for hematoma expansion after intracerebral hemorrhage (ICH). A revised definition of hematoma expansion that incorporates intraventricular hemorrhage (IVH) growth, that is, revised hematoma expansion (RHE), has also been proposed. Nevertheless, the associations between FIM and IVH growth or RHE remains unexplored. The objective of this study was to assess the influence and performance of the FIM on two types. MATERIALS AND METHODS Patient selection and variables were based on our published protocol. FIM was defined as the ratio of the number of imaging markers to the onset-to-neuroimaging time. The association between FIM and two definitions was tested by multivariate analysis. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the FIM on two definitions were also evaluated. RESULTS There were 303 (20.36%) and 583 (39.18%) subjects in the IVH growth and RHE, respectively. Multivariate analysis demonstrated that FIM was associated with both IVH growth and RHE (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 1.60-2.39; OR = 15.01, 95% CI = 10.51-21.43, respectively). The optimal cutoff points for FIM to predict IVH growth and RHE were 0.63 and 0.62, with AUC, sensitivity, specificity, PPV, and NPV of 0.66, 0.50, 0.78, 0.36, and 0.86 versus 0.80, 0.60, 0.93, 0.84, and 0.78, respectively. DISCUSSION AND CONCLUSION FIM was not only a predictor of IVH growth, but also of RHE. These findings may have important clinical implications for decision-making based on risk stratification of patients with ICH.
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Affiliation(s)
- Lei Song
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hang Zhou
- Department of Radiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Jun Cheng
- Computer School, Hubei Polytechnic University, Huangshi, China
| | - Wenmin Guo
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Yu Ye
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Rujia Wang
- Department of Radiology, Tangshan Gongren Hospital, Tangshan, China
| | - Jiao Chen
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Hui Xiong
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Ji Zhang
- Department of Clinical Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Dongfang Tang
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Liwei Zou
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lianghong Kuang
- Department of Neurology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Xiaoming Qiu
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Tingting Guo
- Department of Nuclear Medicine, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
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Ali M, van Etten ES, Akoudad S, Schaafsma JD, Visser MC, Ali M, Cordonnier C, Sandset EC, Klijn CJM, Ruigrok YM, Wermer MJH. Haemorrhagic stroke and brain vascular malformations in women: risk factors and clinical features. Lancet Neurol 2024; 23:625-635. [PMID: 38760100 DOI: 10.1016/s1474-4422(24)00122-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/18/2024] [Accepted: 03/14/2024] [Indexed: 05/19/2024]
Abstract
Haemorrhagic stroke is a severe condition with poor prognosis. Biological sex influences the risk factors, presentations, treatment, and patient outcomes of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and vascular malformations. Women are usually older at onset of intracerebral haemorrhage compared with men but have an increased risk of aneurysmal subarachnoid haemorrhage as they age. Female-specific factors such as pregnancy, eclampsia or pre-eclampsia, postmenopausal status, and hormone therapy influence a woman's long-term risk of haemorrhagic stroke. The presence of intracranial aneurysms, arteriovenous malformations, or cavernous malformations poses unique clinical dilemmas during pregnancy and delivery. In the absence of evidence-based guidelines for managing the low yet uncertain risk of haemorrhagic stroke during pregnancy and delivery in women with vascular malformations, multidisciplinary teams should carefully assess the risks and benefits of delivery methods for these patients. Health-care providers should recognise and address the challenges that women might have to confront when recovering from haemorrhagic stroke.
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Affiliation(s)
- Mariam Ali
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.
| | - Ellis S van Etten
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Saloua Akoudad
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joanna D Schaafsma
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marieke C Visser
- Department of Neurology, Amsterdam University Medical Centre, Location AMC, Amsterdam, Netherlands
| | - Mahsoem Ali
- Department of Surgery, Amsterdam University Medical Centre, Location VUmc, Amsterdam, Netherlands
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, UMR-S1172, Lille Neuroscience and Cognition, Lille, France
| | - Else Charlotte Sandset
- Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marieke J H Wermer
- Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
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Zhang M, Liu T. Efficacy and safety of tranexamic acid in acute traumatic brain injury: A meta-analysis of randomized controlled trials. Am J Emerg Med 2024; 80:35-43. [PMID: 38502985 DOI: 10.1016/j.ajem.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/10/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) holds a pivotal role in the therapeutic approach to traumatic conditions. Nevertheless, its precise influence on diminishing mortality and limiting the progression of intracranial hemorrhage (ICH) during the treatment of traumatic brain injury (TBI) remains indeterminate. METHODS PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials that compared TXA and a placebo in adults with TBI up to September 31, 2023. Two authors independently abstracted the data and assessed the quality of evidence. Additionally, subgroup analyses were performed to assess outcomes with low heterogenety. RESULTS Our search strategy yielded 11,299 patients from 11 studies. The result showed that TXA had no effect on mortality (RR 0.93 [0.86, 1.00], p = 0.06; I2: 0%, p = 0.79), poor clinical outcomes (RR 0.92 [0.78, 1.09], p = 0.34; I2: 0%, p = 0.40), adverse events (RR 0.94 [0.83, 1.07], p = 0.34; I2: 48%, p = 0.10), vascular occlusive events (RR 0.85 [0.68, 1.06], p = 0.16; I2: 32%, p = 0.22), pulmonary embolism (RR 0.76 [0.47, 1.22], p = 0.26; I2: 0%, p = 0.83), seizure (RR 1.11 [0.92, 1.35], p = 0.27; I2: 0%, p = 0.49) and hemorrhagic complications (RR 0.78 [0.55, 1.09], p = 0.14; I2: 0%, p = 0.42). TXA might reduce the rate of hemorrhagic expansion (RR 0.83 [0.70, 0.99], p = 0.03; I2: 18%, p = 0.29) and mean hemorrhage volume (SMD -0.39 [-0.60, -0.18], p <0.001; I2: 44%, p = 0.13).When the time interval from symptom onset to treatment was <3 h, TXA reduced mean hemorrhage volume (SMD -0.51 [-0.81, -0.20], p = 0.001; I2: 0%, p = 0.94). CONCLUSIONS TXA did not elevate the risk of adverse event, however, the lack of reduction in mortality and the poor clinical outcomes constrain the value of clinical application. Early administration of TXA (within 3 h) may significantly decrease the likelihood of ICH growth in patients with TBI.
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Affiliation(s)
- Minzhi Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central NervousSystem, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China.
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Hollingworth M, Woodhouse LJ, Law ZK, Ali A, Krishnan K, Dineen RA, Christensen H, England TJ, Roffe C, Werring D, Peters N, Ciccone A, Robinson T, Członkowska A, Bereczki D, Egea-Guerrero JJ, Ozturk S, Bath PM, Sprigg N. The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial. Neurosurgery 2024:00006123-990000000-01177. [PMID: 38785451 DOI: 10.1227/neu.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set. METHODS Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not. RESULTS Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P-value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P-value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P-value = .45). CONCLUSION TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.
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Affiliation(s)
- Milo Hollingworth
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhe K Law
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Azlinawati Ali
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Faculty of Health Sciences, School of Medical Imaging, University of Sultan Zainal Abidin, Kuala Nerus, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, UK
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle under Lyme, UK
| | - David Werring
- Stroke Research Centre, Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Nils Peters
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alfonso Ciccone
- Azienda Socio Sanitaria Territoriale di Mantova, Mantova, Italy
| | | | | | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Serefnur Ozturk
- Department of Neurology, Neurointensive Care- Stroke Center, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
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18
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Ling Y, Tariq MB, Tang K, Aronowski J, Fann Y, Savitz SI, Jiang X, Kim Y. An interpretable framework to identify responsive subgroups from clinical trials regarding treatment effects: Application to treatment of intracerebral hemorrhage. PLOS DIGITAL HEALTH 2024; 3:e0000493. [PMID: 38713647 DOI: 10.1371/journal.pdig.0000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
Randomized Clinical trials (RCT) suffer from a high failure rate which could be caused by heterogeneous responses to treatment. Despite many models being developed to estimate heterogeneous treatment effects (HTE), there remains a lack of interpretable methods to identify responsive subgroups. This work aims to develop a framework to identify subgroups based on treatment effects that prioritize model interpretability. The proposed framework leverages an ensemble uplift tree method to generate descriptive decision rules that separate samples given estimated responses to the treatment. Subsequently, we select a complementary set of these decision rules and rank them using a sparse linear model. To address the trial's limited sample size problem, we proposed a data augmentation strategy by borrowing control patients from external studies and generating synthetic data. We apply the proposed framework to a failed randomized clinical trial for investigating an intracerebral hemorrhage therapy plan. The Qini-scores show that the proposed data augmentation strategy plan can boost the model's performance and the framework achieves greater interpretability by selecting complementary descriptive rules without compromising estimation quality. Our model derives clinically meaningful subgroups. Specifically, we find those patients with Diastolic Blood Pressure≥70 mm hg and Systolic Blood Pressure<215 mm hg benefit more from intensive blood pressure reduction therapy. The proposed interpretable HTE analysis framework offers a promising potential for extracting meaningful insight from RCTs with neutral treatment effects. By identifying responsive subgroups, our framework can contribute to developing personalized treatment strategies for patients more efficiently.
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Affiliation(s)
- Yaobin Ling
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Muhammad Bilal Tariq
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Kaichen Tang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Yang Fann
- Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Xiaoqian Jiang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Yejin Kim
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
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19
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Fortunato M, Subah G, Thomas AD, Nolan B, Mureb M, Uddin A, Upadhyay K, Ogulnick JV, Damodara N, Bond C, Gandhi CD, Mayer SA, Al-Mufti F. Ultra-Early Hemostatic Therapy for Acute Intracerebral Hemorrhage: An Updated Review. Cardiol Rev 2024; 32:194-202. [PMID: 38517253 DOI: 10.1097/crd.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Intracerebral hemorrhage (ICH) is the second most common type of stroke, accounting for approximately 10-20% of all strokes, and is linked to severe neurological disability and death. Since the most accurate predictor of outcome in patients with ICH is hematoma volume, there is a great need for pharmacologic therapy that can reduce hematoma expansion and resultant mass effect and edema. This is especially critical within the ultra-early window of 3-4 hours after the presentation. Hemostatic therapies are exceptionally important for those patients taking antiplatelet or anticoagulant medications to reverse the effects of these medications and therefore prevent hematoma expansion. Furthermore, the recent publication of the 2023 Guideline for the Management of Patients with Aneurysmal Subarachnoid Hemorrhage by the American Heart Association/American Stroke Association, the first update to the guidelines since 2012, underscores the importance of optimizing anticoagulation reversal for this population. The purpose of this selective, nonsystematic review is to examine current literature regarding the use of hemostatic therapies in ICH, with particular attention paid to antiplatelet, anticoagulation, and antifibrinolytic therapies.
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Affiliation(s)
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Anish D Thomas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Monica Mureb
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Anaz Uddin
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kiran Upadhyay
- Department of Medicine, New York University Langone, Long Island, Mineola, NY
| | | | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Colleen Bond
- Department of Pharmacy, Westchester Medical Center, Valhalla, NY
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
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20
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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21
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Sieh L, Peasley E, Mao E, Mitchell A, Heinonen G, Ghoshal S, Agarwal S, Park S, Connolly ESS, Claassen J, Moore EE, Hansen K, Hod EA, Francis RO, Roh D. Admission viscoelastic hemostatic assay parameters predict poor long-term intracerebral hemorrhage outcomes. RESEARCH SQUARE 2024:rs.3.rs-4087284. [PMID: 38585893 PMCID: PMC10996822 DOI: 10.21203/rs.3.rs-4087284/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background Viscoelastic hemostatic assays (VHA) provide more comprehensive assessments of coagulation compared to conventional coagulation assays. While VHAs have enabled guided hemorrhage control therapies, improving clinical outcomes in life-threatening hemorrhage, the role of VHAs in intracerebral hemorrhage (ICH) is unclear. If VHAs can identify coagulation abnormalities relevant for ICH outcomes, this would support the need to investigate the role of VHAs in ICH treatment paradigms. Thus, we investigated whether VHA assessments of coagulation relate to long-term ICH outcomes. Methods Spontaneous ICH patients enrolled into a single-center cohort study receiving admission Rotational Thromboelastometry (ROTEM) VHA testing between 2013 and 2020 were assessed. Patients with prior anticoagulant use or coagulopathy on conventional coagulation assays were excluded. Primary ROTEM exposure variables were coagulation kinetics and clot strength assessments. Poor long-term outcome was defined as modified Rankin Scale ≥ 4 at 6 months. Logistic regression analyses assessed associations of ROTEM parameters with clinical outcomes after adjusting for ICH severity and hemoglobin concentration. Results Of 44 patients analyzed, mean age was 64, 57% were female, and the median ICH volume was 23 mL. Poor 6-month outcome was seen in 64%. In our multivariable regression models, slower, prolonged coagulation kinetics (adjusted OR for every second increase in clot formation time: 1.04, 95% CI: 1.00-1.09, p = 0.04) and weaker clot strength (adjusted OR for every millimeter increase of maximum clot firmness: 0.84, 95% CI: 0.71-0.99, p = 0.03) were separately associated with poor long-term outcomes. Conclusions Slower, prolonged coagulation kinetics and weaker clot strength on admission VHA ROTEM testing, not attributable to anticoagulant use, were associated with poor long-term outcomes after ICH. Further work is needed to clarify the generalizability and the underlying mechanisms of these VHA findings to assess whether VHA guided treatments should be incorporated into ICH care.
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Affiliation(s)
- Laura Sieh
- Columbia University Vagelos College of Physicians and Surgeons
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22
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McQuilten ZK, Wood EM, Medcalf RL. When to use tranexamic acid for the treatment of major bleeding? J Thromb Haemost 2024; 22:581-593. [PMID: 37827378 DOI: 10.1016/j.jtha.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
Tranexamic acid (TXA) is an antifibrinolytic agent originally developed for the management of bleeding in the setting of postpartum hemorrhage (PPH). Over the last 15 years, there has been accumulating evidence on the use of TXA for the treatment of active bleeding in a variety of clinical contexts. Clinical trials have shown that the efficacy and safety of TXA for the treatment of bleeding differ according to the clinical context in which it is being administered, timing of administration, and dose. Early administration is important for efficacy, particularly in trauma and PPH. Further studies are needed to understand the mechanisms by which TXA provides benefit, optimal modes of administration and dosing, and its effect in some clinical settings, such as spontaneous intracerebral hemorrhage. There is no evidence that TXA increases the risk of thrombotic events in patients with major bleeding overall. However, there is evidence of increased risk of venous thrombosis in patients with gastrointestinal bleeding. There is also evidence of increased risk of seizures with the use of higher doses. This review summarizes the current evidence for the use of TXA for patients with active bleeding and highlights the importance of generating evidence of efficacy and safety of hemostatic interventions specific to the bleeding contexts-as findings from 1 clinical setting may not be generalizable to other contexts-and that of individual patient assessment for bleeding, thrombotic, and other risks, as well as important logistical and other practical considerations, to optimize care and outcomes in these settings.
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Affiliation(s)
- Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia.
| | - Erica M Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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23
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Li S, Liu M, Yang J, Yan X, Wu Y, Zhang L, Zeng M, Zhou D, Peng Y, Sessler DI. Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial. J Clin Anesth 2024; 92:111285. [PMID: 37857168 DOI: 10.1016/j.jclinane.2023.111285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
STUDY OBJECTIVES Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections. DESIGN Randomized, double-blind, placebo-controlled, non-inferiority trial. SETTING Beijing Tiantan Hospital, Capital Medical University. PATIENTS 600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022. INTERVENTIONS Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300). MEASUREMENT The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma. MAIN RESULTS All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures. CONCLUSION Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery. REGISTRY INFORMATION This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.
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Affiliation(s)
- Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jingchao Yang
- Department of Anesthesiology, Cancer Hospital, Chinses Academy of Medical Sciences, Beijing, PR China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Dabiao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; Outcome Research Consortium, Cleveland, OH, USA.
| | - Daniel I Sessler
- Outcome Research Consortium, Cleveland, OH, USA; Department of Outcome Research, Cleveland Clinic, Cleveland, OH, USA.
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24
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Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
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Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
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25
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Song L, Qiu X, Zhang C, Zhou H, Guo W, Ye Y, Wang R, Xiong H, Zhang J, Tang D, Zou L, Wang L, Yu Y, Guo T. Combining Non-Contrast CT Signs With Onset-to-Imaging Time to Predict the Evolution of Intracerebral Hemorrhage. Korean J Radiol 2024; 25:166-178. [PMID: 38238018 PMCID: PMC10831293 DOI: 10.3348/kjr.2023.0591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/05/2023] [Accepted: 11/19/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE This study aimed to determine the predictive performance of non-contrast CT (NCCT) signs for hemorrhagic growth after intracerebral hemorrhage (ICH) when stratified by onset-to-imaging time (OIT). MATERIALS AND METHODS 1488 supratentorial ICH within 6 h of onset were consecutively recruited from six centers between January 2018 and August 2022. NCCT signs were classified according to density (hypodensities, swirl sign, black hole sign, blend sign, fluid level, and heterogeneous density) and shape (island sign, satellite sign, and irregular shape) features. Multivariable logistic regression was used to evaluate the association between NCCT signs and three types of hemorrhagic growth: hematoma expansion (HE), intraventricular hemorrhage growth (IVHG), and revised HE (RHE). The performance of the NCCT signs was evaluated using the positive predictive value (PPV) stratified by OIT. RESULTS Multivariable analysis showed that hypodensities were an independent predictor of HE (adjusted odds ratio [95% confidence interval] of 7.99 [4.87-13.40]), IVHG (3.64 [2.15-6.24]), and RHE (7.90 [4.93-12.90]). Similarly, OIT (for a 1-h increase) was an independent inverse predictor of HE (0.59 [0.52-0.66]), IVHG (0.72 [0.64-0.81]), and RHE (0.61 [0.54-0.67]). Blend and island signs were independently associated with HE and RHE (10.60 [7.36-15.30] and 10.10 [7.10-14.60], respectively, for the blend sign and 2.75 [1.64-4.67] and 2.62 [1.60-4.30], respectively, for the island sign). Hypodensities demonstrated low PPVs of 0.41 (110/269) or lower for IVHG when stratified by OIT. When OIT was ≤ 2 h, the PPVs of hypodensities, blend sign, and island sign for RHE were 0.80 (215/269), 0.90 (142/157), and 0.83 (103/124), respectively. CONCLUSION Hypodensities, blend sign, and island sign were the best NCCT predictors of RHE when OIT was ≤ 2 h. NCCT signs may assist in earlier recognition of the risk of hemorrhagic growth and guide early intervention to prevent neurological deterioration resulting from hemorrhagic growth.
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Affiliation(s)
- Lei Song
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Xiaoming Qiu
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Cun Zhang
- Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Hang Zhou
- Department of Radiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Wenmin Guo
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Yu Ye
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Rujia Wang
- Department of Radiology, Tangshan Gongren Hospital, Tangshan, China
| | - Hui Xiong
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Ji Zhang
- Department of Clinical Laboratory, Xiangyang Central Haspital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Dongfang Tang
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Liwei Zou
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Longsheng Wang
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yongqiang Yu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Tingting Guo
- Department of Nuclear Medicine, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China.
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26
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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27
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Zou D, Chen X, Chen S, Zhang P, Lu Y. Impact of Endoscopic Surgery Versus Robot CAS-R-2 Assisted with Stereotactic Drainage on Prognosis of Basal Ganglia Hypertensive Intracerebral Hemorrhage. World Neurosurg 2024; 181:e589-e596. [PMID: 37898270 DOI: 10.1016/j.wneu.2023.10.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE To evaluate the impact of endoscopic surgery (ES) versus robot CAS-R-2 assisted with stereotactic drainage on prognosis of basal ganglia hypertensive intracerebral hemorrhage (HICH). METHODS This retrospective observational study included patients who underwent ES or robot CAS-R-2 assisted with stereotactic drainage for basal ganglia HICH in Shanghai Sixth People's Hospital between June 2017 and May 2022. The outcomes were 6-month mortality and modified Rankin Scale (mRS) score. RESULTS A total of 94 patients were included; 68 (age 51.26 ± 9.18 years, 17 women) of them underwent ES, while the other 26 (age 56.50 ± 12.91, 11 women) underwent robot CAS-R-2. The 6-month mortality rates were similar (P > 0.05) between the patients who underwent ES (6 of 68, 8.82%) and robot CAS-R-2 (2 of 26,7.69%), while the rate of good prognosis in the ES group was significantly higher compared with that in the robot CAS-R-2 group (P = 0.024). Univariate logistic analysis found that endoscopic surgery, age, and hematoma volume were associated with poor prognosis at 6 months. Multivariate logistic regression analysis showed that, after adjusted for the preoperative hematoma volume and age, endoscopy surgery (relative risk 0.21, 95% CI 0.06-0.68, P = 0.009) was associated with good prognosis at 6 months follow-up. CONCLUSIONS Compared with robot CAS-R-2 assisted with stereotactic drainage, ES might have higher rate of good prognosis at 6-month follow-up for basal ganglia HICH.
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Affiliation(s)
- Dongdong Zou
- Department of Neurosurgery, The Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xin Chen
- Department of Neurosurgery, The Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Shuping Chen
- Intensive Care Unit, The Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China.
| | - Pengqi Zhang
- Department of Neurosurgery, The Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Youming Lu
- Department of Neurosurgery, The Affiliated Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Yu W, Zhou L, Shi Z, Mao J, Li Z, Chen X, Tan G, Wang Z, Chen S. Hematoma Enlargement After Intracerebral Hemorrhage: A Bibliometric Analysis. World Neurosurg 2024; 181:e713-e721. [PMID: 37898277 DOI: 10.1016/j.wneu.2023.10.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 10/30/2023]
Abstract
OBJECTIVE To conduct a quantitative analysis of published studies on hematoma enlargement after intracerebral hemorrhage. METHODS Studies on hematoma enlargement after cerebral hemorrhage were retrieved from the Web of Science database on June 30, 2023. Microsoft Excel, VOSviewer, and CiteSpace software were used for bibliometric analysis and visualization, focusing on the quantitative characteristics of the literature. RESULTS A total of 444 articles were published in 161 journals, with 2161 authors from 41 countries and 717 institutions. The most published authors, countries, and institutions were Goldstein, the USA, and Massachusetts General Hospital. Stroke published the most studies, but the average citation number per year of Lancet Neurology far exceeded that of other journals. The research field of hematoma enlargement is mainly divided into 3 focuses, including mechanisms, identification (computed tomography signs, predictive models), and treatment (hemostasis, antihypertensive therapy). Most bursts in publication number have been since 2010, where the highest burst was from research on spot signs, and the latest burst focused on tranexamic acid. Treatment using tranexamic acid based on different computed tomography signs is a focus of current research, but the effectiveness still requires further exploration. CONCLUSIONS This bibliometric analysis analyzed the research framework and hotspots on hematoma enlargement after cerebral hemorrhage, which can help researchers better understand this field and provide potential suggestions for collaborations and research.
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Affiliation(s)
- Weijie Yu
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Liwei Zhou
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhongjie Shi
- School of Medicine, Xiamen University, Xiamen, China
| | - Jianyao Mao
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhangyu Li
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Xi Chen
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Guowei Tan
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhanxiang Wang
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Sifang Chen
- Department of Neurosurgery, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China; The School of Clinical Medicine, Fujian Medical University, Fuzhou, China.
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Connors JM, Fein S. How to manage ITP with life-threatening bleeding. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:254-258. [PMID: 38066888 PMCID: PMC10727002 DOI: 10.1182/hematology.2023000478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
While immune thrombocytopenia often presents with mild bleeding manifestations or surprising findings of thrombocytopenia on routine complete blood counts in patients without symptoms, some patients can present with new thrombocytopenia and life-threatening bleeding. Emergent assessment and treatment are needed to prevent substantial morbidity and even mortality. These patients present to the emergency room with bleeding, and hematologists are subsequently consulted. Understanding the approach to making the diagnosis and excluding other life-threatening illnesses is essential, as is rapid initiation of treatment in the bleeding patient even when the diagnosis of immune- mediated thrombocytopenia is tentative. Using a case-based format, we review how to approach and treat patients presenting with new thrombocytopenia and bleeding.
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Affiliation(s)
- Jean M Connors
- Division of Hematology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Jin Y, Huang YH, Chen YP, Zhang YD, Li J, Yang KC, Ye X, Jin LH, Wu J, Yuan CZ, Gao F, Tong LS. Combined effect of cortical superficial siderosis and cerebral microbleed on short-term and long-term outcomes after intracerebral haemorrhage. Stroke Vasc Neurol 2023:svn-2023-002439. [PMID: 37949481 DOI: 10.1136/svn-2023-002439] [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: 03/01/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND AND PURPOSE Cortical superficial siderosis (cSS) and cerebral microbleed (CMB) have distinct effects on intracerebral haemorrhage (ICH). We aim to investigate the combined effect of cSS and CMB on outcomes after ICH. METHODS Based on a single-centre stroke registry database, patients with spontaneous ICH who had CT scan within 48 hours after ictus and MRI subsequently were identified. Eligible patients were divided into four groups (cSS-CMB-, cSS-CMB+, cSS+CMB-, cSS+CMB+) according to cSS and CMB on susceptibility-weighted image of MRI. Primary outcomes were haematoma volume on admission and unfavourable outcome defined as modified Rankin Scale scores ≥3 at 3 months. Secondary outcomes were all-cause death, recurrence of stroke and ICH during follow-up (median follow-up 2.0 years, IQR 1.0-3.0 years). RESULTS A total of 673 patients were identified from 1044 patients with spontaneous ICH. 131 (19.5%) had cSS and 468 (69.5%) had CMB. Patients with cSS+CMB+ had the highest rate of poor outcome at 3 months, as well as all-cause death, recurrent stroke and ICH during follow-up. In cSS- patients, CMB was associated with smaller haematoma (β -0.13; 95% CI -0.22 to -0.03; p=0.009), but it still increased risks of recurrent ICH (OR 4.6; 95% CI 1.3 to 15.6; p=0.015) and stroke (OR 2.0; 95% CI 1.0 to 4.0; p=0.049). These effects of CMB became unremarkable in the context of cSS+. CONCLUSIONS Patients with different combinations of cSS and CMB have distinct patterns of short-term and long-term outcomes. Although CMB is related to restrained haematoma, it does not improve long-term outcomes. TRIAL REGISTRATION NUMBER NCT04803292.
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Affiliation(s)
- Yujia Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yu-Hui Huang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Yu-Ping Chen
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yao-Dan Zhang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Jiawen Li
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Kai-Cheng Yang
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xianghua Ye
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Hang Jin
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Neurology, Tiantai People's Hospital of Zhejiang Province, Taizhou, China
| | | | - Feng Gao
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Lu-Sha Tong
- Neurology Department, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Chen ZF, Zhang L, Carrington AM, Thornhill R, Miguel O, Auriat AM, Omid-Fard N, Hiremath S, Tshemeister Abitbul V, Dowlatshahi D, Demchuk A, Gladstone D, Morotti A, Casetta I, Fainardi E, Huynh T, Elkabouli M, Talbot Z, Melkus G, Aviv RI. Clinical Features, Non-Contrast CT Radiomic and Radiological Signs in Models for the Prediction of Hematoma Expansion in Intracerebral Hemorrhage. Can Assoc Radiol J 2023; 74:713-722. [PMID: 37070854 DOI: 10.1177/08465371231168383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
PURPOSE Rapid identification of hematoma expansion (HE) risk at baseline is a priority in intracerebral hemorrhage (ICH) patients and may impact clinical decision making. Predictive scores using clinical features and Non-Contract Computed Tomography (NCCT)-based features exist, however, the extent to which each feature set contributes to identification is limited. This paper aims to investigate the relative value of clinical, radiological, and radiomics features in HE prediction. METHODS Original data was retrospectively obtained from three major prospective clinical trials ["Spot Sign" Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy (SPOTLIGHT)NCT01359202; The Spot Sign for Predicting and Treating ICH Growth Study (STOP-IT)NCT00810888] Patients baseline and follow-up scans following ICH were included. Clinical, NCCT radiological, and radiomics features were extracted, and multivariate modeling was conducted on each feature set. RESULTS 317 patients from 38 sites met inclusion criteria. Warfarin use (p=0.001) and GCS score (p=0.046) were significant clinical predictors of HE. The best performing model for HE prediction included clinical, radiological, and radiomic features with an area under the curve (AUC) of 87.7%. NCCT radiological features improved upon clinical benchmark model AUC by 6.5% and a clinical & radiomic combination model by 6.4%. Addition of radiomics features improved goodness of fit of both clinical (p=0.012) and clinical & NCCT radiological (p=0.007) models, with marginal improvements on AUC. Inclusion of NCCT radiological signs was best for ruling out HE whereas the radiomic features were best for ruling in HE. CONCLUSION NCCT-based radiological and radiomics features can improve HE prediction when added to clinical features.
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Affiliation(s)
| | - Liying Zhang
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - André M Carrington
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
| | - Rebecca Thornhill
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Olivier Miguel
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Angela M Auriat
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Nima Omid-Fard
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Shivaprakash Hiremath
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Vered Tshemeister Abitbul
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Dar Dowlatshahi
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine (Neurology), University of Ottawa, Ottawa, ON, Canada
| | - Andrew Demchuk
- Department of Medicine (Neurology), Foothills Medical Center, Calgary, AB, Canada
| | - David Gladstone
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ilaria Casetta
- Neurological Clinic, University of Ferrara, Ferrara, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
| | - Thien Huynh
- Departments of Radiology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Zoé Talbot
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gerd Melkus
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
| | - Richard I Aviv
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa, Ottawa, ON, Canada
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Eilertsen H, Menon CS, Law ZK, Chen C, Bath PM, Steiner T, Desborough MJ, Sandset EC, Sprigg N, Al-Shahi Salman R. Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 10:CD005951. [PMID: 37870112 PMCID: PMC10591281 DOI: 10.1002/14651858.cd005951.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Outcome after acute spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume. ICH expansion occurs in about 20% of people with acute ICH. Early haemostatic therapy might improve outcome by limiting ICH expansion. This is an update of a Cochrane Review first published in 2006, and last updated in 2018. OBJECTIVES To examine 1. the effects of individual classes of haemostatic therapies, compared with placebo or open control, in adults with acute spontaneous ICH, and 2. the effects of each class of haemostatic therapy according to the use and type of antithrombotic drug before ICH onset. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL (2022, Issue 8), MEDLINE Ovid, and Embase Ovid on 12 September 2022. To identify further published, ongoing, and unpublished randomised controlled trials (RCTs), we scanned bibliographies of relevant articles and searched international registers of RCTs in September 2022. SELECTION CRITERIA We included RCTs of any haemostatic intervention (i.e. procoagulant treatments such as clotting factor concentrates, antifibrinolytic drugs, platelet transfusion, or agents to reverse the action of antithrombotic drugs) for acute spontaneous ICH, compared with placebo, open control, or an active comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was death/dependence (modified Rankin Scale (mRS) 4 to 6) by day 90. Secondary outcomes were ICH expansion on brain imaging after 24 hours, all serious adverse events, thromboembolic adverse events, death from any cause, quality of life, mood, cognitive function, Barthel Index score, and death or dependence measured on the Extended Glasgow Outcome Scale by day 90. MAIN RESULTS We included 20 RCTs involving 4652 participants: nine RCTs of recombinant activated factor VII (rFVIIa) versus placebo/open control (1549 participants), eight RCTs of antifibrinolytic drugs versus placebo/open control (2866 participants), one RCT of platelet transfusion versus open control (190 participants), and two RCTs of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) (47 participants). Four (20%) RCTs were at low risk of bias in all criteria. For rFVIIa versus placebo/open control for spontaneous ICH with or without surgery there was little to no difference in death/dependence by day 90 (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.05; 7 RCTs, 1454 participants; low-certainty evidence). We found little to no difference in ICH expansion between groups (RR 0.81, 95% CI 0.56 to 1.16; 4 RCTs, 220 participants; low-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 0.81, 95% CI 0.30 to 2.22; 2 RCTs, 87 participants; very low-certainty evidence; death from any cause: RR 0.78, 95% CI 0.56 to 1.08; 8 RCTs, 1544 participants; moderate-certainty evidence). For antifibrinolytic drugs versus placebo/open control for spontaneous ICH, there was no difference in death/dependence by day 90 (RR 1.00, 95% CI 0.93 to 1.07; 5 RCTs, 2683 participants; high-certainty evidence). We found a slight reduction in ICH expansion with antifibrinolytic drugs for spontaneous ICH compared to placebo/open control (RR 0.86, 95% CI 0.76 to 0.96; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.02, 95% CI 0.75 to 1.39; 4 RCTs, 2599 participants; high-certainty evidence; death from any cause: RR 1.02, 95% CI 0.89 to 1.18; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in quality of life, mood, or cognitive function (quality of life: mean difference (MD) 0, 95% CI -0.03 to 0.03; 2 RCTs, 2349 participants; mood: MD 0.30, 95% CI -1.98 to 2.57; 2 RCTs, 2349 participants; cognitive function: MD -0.37, 95% CI -1.40 to 0.66; 1 RCTs, 2325 participants; all high-certainty evidence). Platelet transfusion likely increases death/dependence by day 90 compared to open control for antiplatelet-associated ICH (RR 1.29, 95% CI 1.04 to 1.61; 1 RCT, 190 participants; moderate-certainty evidence). We found little to no difference in ICH expansion between groups (RR 1.32, 95% CI 0.91 to 1.92; 1 RCT, 153 participants; moderate-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.46, 95% CI 0.98 to 2.16; 1 RCT, 190 participants; death from any cause: RR 1.42, 95% CI 0.88 to 2.28; 1 RCT, 190 participants; both moderate-certainty evidence). For PCC versus FFP for anticoagulant-associated ICH, the evidence was very uncertain about the effect on death/dependence by day 90, ICH expansion, all serious adverse events, and death from any cause between groups (death/dependence by day 90: RR 1.21, 95% CI 0.76 to 1.90; 1 RCT, 37 participants; ICH expansion: RR 0.54, 95% CI 0.23 to 1.22; 1 RCT, 36 participants; all serious adverse events: RR 0.27, 95% CI 0.02 to 3.74; 1 RCT, 5 participants; death from any cause: RR 0.49, 95% CI 0.16 to 1.56; 2 RCTs, 42 participants; all very low-certainty evidence). AUTHORS' CONCLUSIONS In this updated Cochrane Review including 20 RCTs involving 4652 participants, rFVIIa likely results in little to no difference in reducing death or dependence after spontaneous ICH with or without surgery; antifibrinolytic drugs result in little to no difference in reducing death or dependence after spontaneous ICH, but result in a slight reduction in ICH expansion within 24 hours; platelet transfusion likely increases death or dependence after antiplatelet-associated ICH; and the evidence is very uncertain about the effect of PCC compared to FFP on death or dependence after anticoagulant-associated ICH. Thirteen RCTs are ongoing and are likely to increase the certainty of the estimates of treatment effect.
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Affiliation(s)
- Helle Eilertsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Philip M Bath
- Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Thorsten Steiner
- Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Jr Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nikola Sprigg
- Stroke Medicine, University of Nottingham, Nottingham, UK
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Sébille V, Dubuy Y, Feuillet F, Blanchin M, Roquilly A, Cinotti R. Does Differential Item Functioning Jeopardize the Comparability of Health-Related Quality of Life Assessment Between Patients and Proxies in Patients with Moderate-to-Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:339-347. [PMID: 36977961 DOI: 10.1007/s12028-023-01705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is clearly recognized as a patient-important outcome in patients with traumatic brain injury (TBI). Patient-reported outcomes are therefore often used and supposed to be directly reported by the patients without interpretation of their responses by a physician or anyone else. However, patients with TBI are often unable to self-report because of physical and/or cognitive impairments. Thus, proxy-reported measures, e.g., family members, are often used on the patient's behalf. Yet, many studies have reported that proxy and patient ratings differ and are noncomparable. However, most studies usually do not account for other potential confounding factors that may be associated with HRQoL. In addition, patients and proxies can interpret some items of the patient-reported outcomes differently. As a result, item responses may not only reflect patients' HRQoL but also the respondent's (patient or proxy) own perception of the items. This phenomenon, called differential item functioning (DIF), can lead to substantial differences between patient-reported and proxy-reported measures and compromise their comparability, leading to highly biased HRQoL estimates. Using data from the prospective multicenter continuous hyperosmolar therapy in traumatic brain-injured patients study (240 patients with HRQoL measured with the Short Form-36 (SF-36)), we assessed the comparability of patients' and proxies' reports by evaluating the extent to which items perception differs (i.e., DIF) between patients and proxies after controlling for potential confounders. METHODS Items at risk of DIF adjusting for confounders were examined on the items of the role physical and role emotional domains of the SF-36. RESULTS Differential item functioning was evidenced in three out of the four items of the role physical domain measuring role limitations due to physical health problems and in one out of the three items of the role emotional domain measuring role limitations due to personal or emotional problems. Overall, despite an expected similar level of role limitations between patients who were able to respond and those for whom proxies responded, proxies tend to give more pessimistic responses than patients in the case of major role limitations and more optimistic responses than patients in the case of minor limitations. CONCLUSIONS Patients with moderate-to-severe TBI and proxies seem to have different perceptions of the items measuring role limitations due to physical or emotional problems, questioning the comparability of patient and proxy data. Therefore, aggregating proxy and patient responses may bias HRQoL estimates and alter medical decision-making based on these patient-important outcomes.
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Affiliation(s)
- Véronique Sébille
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France.
- DRCI, Methodology and Biostatistic Department, CHU Nantes, Nantes, France.
- SPHERE, Nantes Université, IRS2 22 Boulevard Bénoni Goullin, 44200, Nantes, France.
| | - Yseulys Dubuy
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
| | - Fanny Feuillet
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
- DRCI, Methodology and Biostatistic Department, CHU Nantes, Nantes, France
| | - Myriam Blanchin
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- Surgical Intensive Care Unit, Hôtel Dieu, CHU Nantes, Nantes, France
| | - Raphaël Cinotti
- Nantes Université, Univ Tours, CHU Nantes, INSERM, MethodS in Patients-centered outcomes and HEalth Research, SPHERE, 44200, Nantes, France
- Surgical Intensive Care Unit, Hôtel Dieu, CHU Nantes, Nantes, France
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Krawchuk LJ, Sharrock MF. Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury. Semin Neurol 2023; 43:699-711. [PMID: 37802120 DOI: 10.1055/s-0043-1775790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.
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Affiliation(s)
- Lindsey J Krawchuk
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew F Sharrock
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Backus B, Beyer-Westendorf J, Body R, Lindner T, Möckel M, Sehgal V, Parry-Jones A, Seiffge D, Gibler B. Management of major bleeding for anticoagulated patients in the Emergency Department: an European experts consensus statement. Eur J Emerg Med 2023; 30:315-323. [PMID: 37427548 DOI: 10.1097/mej.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
An increasing number of patients presenting to the emergency department (ED) with life-threatening bleeding are using oral anticoagulants, such as warfarin, Factor IIa and Factor Xa inhibitors. Achieving rapid and controlled haemostasis is critically important to save the patient's life. This multidisciplinary consensus paper provides a systematic and pragmatic approach to the management of anticoagulated patients with severe bleeding at the ED. Repletion and reversal management of the specific anticoagulants is described in detail. For patients on vitamin K antagonists, the administration of vitamin K and repletion of clotting factors with four-factor prothrombin complex concentrate provides real-time ability to stop the bleeding. For patients using a direct oral anticoagulant, specific antidotes are necessary to reverse the anticoagulative effect. For patients receiving the thrombin inhibitor dabigatran, treatment with idarucizamab has been demonstrated to reverse the hypocoagulable state. For patients receiving a factor Xa inhibitor (apixaban or rivaroxaban), andexanet alfa is the indicated antidote in patients with major bleeding. Lastly, specific treatment strategies are discussed in patients using anticoagulants with major traumatic bleeding, intracranial haemorrhage or gastrointestinal bleeding.
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Affiliation(s)
- Barbra Backus
- Emergency Department, Franciscus Gasthuis and Vlietland, Rotterdam
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Rick Body
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tobias Lindner
- Emergency and Acute Medicine, Campus Virchow, Charité - Universitätsmedizin, Berlin, Germany
| | - Martin Möckel
- Emergency and Acute Medicine, Campus Virchow, Charité - Universitätsmedizin, Berlin, Germany
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospital, London
| | - Adrian Parry-Jones
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Seiffge
- Department of Neurology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Brian Gibler
- University of Cincinnati College of Medicine President, Department of Emergency Medicine, Cincinnati, Ohio, USA
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Li Q, Morotti A, Warren A, Qureshi AI, Dowlatshahi D, Falcone G, Sheth KN, Shoamanesh A, Murthy SB, Viswanathan A, Goldstein JN. Intensive Blood Pressure Reduction is Associated with Reduced Hematoma Growth in Fast Bleeding Intracerebral Hemorrhage. Ann Neurol 2023. [PMID: 37706569 DOI: 10.1002/ana.26795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/26/2023] [Accepted: 08/29/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE Patients with spontaneous intracerebral hemorrhage (ICH) at the highest risk of hematoma growth are those with the most potential to benefit from anti-expansion treatment. Large clinical trials have not definitively shown a clear benefit of blood pressure (BP) reduction. We aim to determine whether intensive blood pressure reduction could benefit patients with fast bleeding ICH. METHODS An exploratory analysis of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) randomized controlled trial was performed. In order to capture not just early bleeding (even if a small amount), but the rate of bleeding (ml/hour), we restricted the study to "Fast bleeding ICH," defined as an ICH volume/onset to computed tomography (CT) time >5 ml/hr. Hematoma growth, as defined as an increase of hematoma volume > 33% between baseline and 24 hours. RESULTS A total of 940 patients were included (mean age = 62.1 years, 61.5% men), of whom 214 (22.8%) experienced hematoma expansion. Of these, 567 (60.3%) met the definition of "fast bleeding" with baseline ICH volume/time to presentation of at least 5 ml/hr. Intensive BP reduction was associated with a significantly lower rate of hematoma growth in fast bleeding patients (20.6% vs 31.0%, p = 0.005). In a subgroup of 266 (46.9%) fast-bleeding patients who received treatment within 2 hours after symptom onset, intensive BP lowering was associated with improved functional independence (odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.06-3.69, p = 0.031). INTERPRETATION Our results suggest that early use of intensive BP reduction may reduce hematoma growth and improve outcome in fast bleeding patients. ANN NEUROL 2023.
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Affiliation(s)
- Qi Li
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Andrew Warren
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Guido Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, and the Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT
| | - Ashkan Shoamanesh
- Department of Medicine, Division of Neurology, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Lam T, Medcalf RL, Cloud GC, Myles PS, Keragala CB. Tranexamic acid for haemostasis and beyond: does dose matter? Thromb J 2023; 21:94. [PMID: 37700271 PMCID: PMC10496216 DOI: 10.1186/s12959-023-00540-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.
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Affiliation(s)
- Tammy Lam
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Robert L Medcalf
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne VIC, Australia
| | - Charithani B Keragala
- Australian Centre for Blood Diseases, Monash AMREP Building, Monash University, Level 1 Walkway, Via The Alfred Centre, 99 Commercial Rd, Melbourne, 3004, Australia.
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Sigmon J, Crowley KL, Groth CM. Therapeutic review: The role of tranexamic acid in management of traumatic brain injury, nontraumatic intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage. Am J Health Syst Pharm 2023; 80:1213-1222. [PMID: 37280158 DOI: 10.1093/ajhp/zxad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 06/08/2023] Open
Abstract
PURPOSE To summarize current literature evaluating tranexamic acid in the management of intracranial bleeding associated with traumatic and nontraumatic brain injuries and implications for clinical practice. SUMMARY Intracranial hemorrhage, regardless of etiology, is associated with high morbidity and mortality. Tranexamic acid is an antifibrinolytic with anti-inflammatory properties shown to reduce mortality in trauma patients with extracranial injuries. In traumatic brain injury, a large randomized trial found no difference in outcomes when tranexamic acid was compared to placebo; however, subgroup analyses suggested that it may reduce head injury-related mortality in the context of mild-to-moderate injury if treatment occurs within 1 hour of symptom onset. More recent out-of-hospital data have disputed these findings and even suggested harm in severely injured patients. In spontaneous, nontraumatic intracranial hemorrhage, treatment with tranexamic acid did not result in a difference in functional status; however, rates of hematoma expansion, even though modest, were significantly reduced. In aneurysmal subarachnoid hemorrhage, tranexamic acid may prevent rebleeding, but has not led to improved outcomes or reduced mortality, and there is concern for increased incidence of delayed cerebral ischemia. Overall, tranexamic acid has not been shown to result in increased risk of thromboembolic complications across these classes of brain injury. CONCLUSION Despite its favorable safety profile overall, tranexamic acid does not seem to improve functional outcomes and cannot be routinely recommended. More data are needed to determine which head injury subpopulations are most likely to benefit from tranexamic acid and which patients are at increased risk for harm.
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Affiliation(s)
| | - Kelli L Crowley
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Polymeris AA, Karwacki GM, Siepen BM, Schaedelin S, Tsakiris DA, Stippich C, Guzman R, Nickel CH, Sprigg N, Kägi G, Vehoff J, Barinka F, Thilemann S, Maurer M, Wagner B, Traenka C, Gensicke H, De Marchis GM, Bonati LH, Fischer U, Z’Graggen WJ, Nedeltchev K, Wegener S, Baumgartner P, Engelter ST, Seiffge DJ, Peters N, Lyrer PA. Tranexamic Acid for Intracerebral Hemorrhage in Patients on Non-Vitamin K Antagonist Oral Anticoagulants (TICH-NOAC): A Multicenter, Randomized, Placebo-Controlled, Phase 2 Trial. Stroke 2023; 54:2223-2234. [PMID: 37466000 PMCID: PMC10453353 DOI: 10.1161/strokeaha.123.042866] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Evidence-based hemostatic treatment for intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOACs) is lacking. Tranexamic acid (TXA) is an antifibrinolytic drug potentially limiting hematoma expansion. We aimed to assess the efficacy and safety of TXA in NOAC-ICH. METHODS We performed a double-blind, randomized, placebo-controlled trial at 6 Swiss stroke centers. Patients with NOAC-ICH within 12 hours of symptom onset and 48 hours of last NOAC intake were randomized (1:1) to receive either intravenous TXA (1 g over 10 minutes followed by 1 g over 8 hours) or matching placebo in addition to standard medical care via a centralized Web-based procedure with minimization on key prognostic factors. All participants and investigators were masked to treatment allocation. Primary outcome was hematoma expansion, defined as ≥33% relative or ≥6 mL absolute volume increase at 24 hours and analyzed using logistic regression adjusted for baseline hematoma volume on an intention-to-treat basis. RESULTS Between December 12, 2016, and September 30, 2021, we randomized 63 patients (median age, 82 years [interquartile range, 76-86]; 40% women; median hematoma volume, 11.5 [4.8-27.4] mL) of the 109 intended sample size before premature trial discontinuation due to exhausted funding. The primary outcome did not differ between TXA (n=32) and placebo (n=31) arms (12 [38%] versus 14 [45%]; adjusted odds ratio, 0.63 [95% CI, 0.22-1.82]; P=0.40). There was a signal for interaction with onset-to-treatment time (Pinteraction=0.024), favoring TXA when administered within 6 hours of symptom onset. Between the TXA and placebo arms, the proportion of participants who died (15 [47%] versus 13 [42%]; adjusted odds ratio, 1.07 [0.37-3.04]; P=0.91) or had major thromboembolic complications within 90 days (4 [13%] versus 2 [6%]; odds ratio, 1.86 [0.37-9.50]; P=0.45) did not differ. All thromboembolic events occurred at least 2 weeks after study treatment, exclusively in participants not restarted on oral anticoagulation. CONCLUSIONS In a smaller-than-intended NOAC-ICH patient sample, we found no evidence that TXA prevents hematoma expansion, but there were no major safety concerns. Larger trials on hemostatic treatments targeting an early treatment window are needed for NOAC-ICH. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT02866838.
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Affiliation(s)
- Alexandros A. Polymeris
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
| | - Grzegorz M. Karwacki
- Department of Radiology and Nuclear Medicine, Luzerner Kantonsspital, Switzerland (G.M.K.)
| | - Bernhard M. Siepen
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (B.M.S., G.K., U.F., W.J.Z., D.J.S.)
- Graduate School of Health Sciences, University of Bern, Switzerland (B.M.S.)
| | - Sabine Schaedelin
- Department of Clinical Research (S.S.), University Hospital Basel and University of Basel, Switzerland
| | | | - Christoph Stippich
- Department of Neuroradiology and Radiology, Kliniken Schmieder, Allensbach, Germany (C.S.)
| | - Raphael Guzman
- Department of Neurosurgery (R.G.), University Hospital Basel and University of Basel, Switzerland
| | - Christian H. Nickel
- Department of Emergency Medicine (C.H.N.), University Hospital Basel and University of Basel, Switzerland
| | - Nikola Sprigg
- Nottingham Stroke Trials Unit, University of Nottingham, United Kingdom (N.S.)
- Stroke Center, Klinik Hirslanden Zurich, Switzerland (F.B., N.P.)
| | - Georg Kägi
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (B.M.S., G.K., U.F., W.J.Z., D.J.S.)
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, Switzerland (G.K., J.V.)
| | - Jochen Vehoff
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, Switzerland (G.K., J.V.)
| | - Filip Barinka
- Stroke Center, Klinik Hirslanden Zurich, Switzerland (F.B., N.P.)
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
| | - Marina Maurer
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (C.T., H.G., S.T.E., N.P.)
| | - Henrik Gensicke
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (C.T., H.G., S.T.E., N.P.)
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
| | - Leo H. Bonati
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Reha Rheinfelden, Switzerland (L.H.B.)
| | - Urs Fischer
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (B.M.S., G.K., U.F., W.J.Z., D.J.S.)
| | - Werner J. Z’Graggen
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (B.M.S., G.K., U.F., W.J.Z., D.J.S.)
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Switzerland (K.N.)
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Switzerland (S.W., P.B.)
| | - Philipp Baumgartner
- Department of Neurology, University Hospital and University of Zurich, Switzerland (S.W., P.B.)
| | - Stefan T. Engelter
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (C.T., H.G., S.T.E., N.P.)
| | - David J. Seiffge
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Department of Neurology, Inselspital, University Hospital and University of Bern, Switzerland (B.M.S., G.K., U.F., W.J.Z., D.J.S.)
| | - Nils Peters
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland (C.T., H.G., S.T.E., N.P.)
| | - Philippe A. Lyrer
- Department of Neurology and Stroke Center (A.A.P., S.T., M.M., B.W., C.T., H.G., G.M.D.M., L.H.B., U.F., S.T.E., D.J.S., N.P., P.A.L.), University Hospital Basel and University of Basel, Switzerland
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Haider SP, Qureshi AI, Jain A, Tharmaseelan H, Berson ER, Zeevi T, Werring DJ, Gross M, Mak A, Malhotra A, Sansing LH, Falcone GJ, Sheth KN, Payabvash S. Radiomic markers of intracerebral hemorrhage expansion on non-contrast CT: independent validation and comparison with visual markers. Front Neurosci 2023; 17:1225342. [PMID: 37655013 PMCID: PMC10467422 DOI: 10.3389/fnins.2023.1225342] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/10/2023] [Indexed: 09/02/2023] Open
Abstract
Objective To devise and validate radiomic signatures of impending hematoma expansion (HE) based on admission non-contrast head computed tomography (CT) of patients with intracerebral hemorrhage (ICH). Methods Utilizing a large multicentric clinical trial dataset of hypertensive patients with spontaneous supratentorial ICH, we developed signatures predictive of HE in a discovery cohort (n = 449) and confirmed their performance in an independent validation cohort (n = 448). In addition to n = 1,130 radiomic features, n = 6 clinical variables associated with HE, n = 8 previously defined visual markers of HE, the BAT score, and combinations thereof served as candidate variable sets for signatures. The area under the receiver operating characteristic curve (AUC) quantified signatures' performance. Results A signature combining select radiomic features and clinical variables attained the highest AUC (95% confidence interval) of 0.67 (0.61-0.72) and 0.64 (0.59-0.70) in the discovery and independent validation cohort, respectively, significantly outperforming the clinical (pdiscovery = 0.02, pvalidation = 0.01) and visual signature (pdiscovery = 0.03, pvalidation = 0.01) as well as the BAT score (pdiscovery < 0.001, pvalidation < 0.001). Adding visual markers to radiomic features failed to improve prediction performance. All signatures were significantly (p < 0.001) correlated with functional outcome at 3-months, underlining their prognostic relevance. Conclusion Radiomic features of ICH on admission non-contrast head CT can predict impending HE with stable generalizability; and combining radiomic with clinical predictors yielded the highest predictive value. By enabling selective anti-expansion treatment of patients at elevated risk of HE in future clinical trials, the proposed markers may increase therapeutic efficacy, and ultimately improve outcomes.
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Affiliation(s)
- Stefan P. Haider
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
- Department of Otorhinolaryngology, University Hospital of Ludwig-Maximilians-Universität München, Munich, Germany
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Abhi Jain
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Hishan Tharmaseelan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Elisa R. Berson
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Tal Zeevi
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - David J. Werring
- Stroke Research Centre, University College London, Queen Square Institute of Neurology, London, United Kingdom
| | - Moritz Gross
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Adrian Mak
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Lauren H. Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Guido J. Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
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Dong W, Gong F, Zhao Y, Bai H, Yang R. Ferroptosis and mitochondrial dysfunction in acute central nervous system injury. Front Cell Neurosci 2023; 17:1228968. [PMID: 37622048 PMCID: PMC10445767 DOI: 10.3389/fncel.2023.1228968] [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: 05/25/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
Acute central nervous system injuries (ACNSI), encompassing traumatic brain injury (TBI), non-traumatic brain injury like stroke and encephalomeningitis, as well as spinal cord injuries, are linked to significant rates of disability and mortality globally. Nevertheless, effective and feasible treatment plans are still to be formulated. There are primary and secondary injuries occurred after ACNSI. Most ACNSIs exhibit comparable secondary injuries, which offer numerous potential therapeutic targets for enhancing clinical outcomes. Ferroptosis, a newly discovered form of cell death, is characterized as a lipid peroxidation process that is dependent on iron and oxidative conditions, which is also indispensable to mitochondria. Ferroptosis play a vital role in many neuropathological pathways, and ACNSIs may induce mitochondrial dysfunction, thereby indicating the essentiality of the mitochondrial connection to ferroptosis in ACNSIs. Nevertheless, there remains a lack of clarity regarding the involvement of mitochondria in the occurrence of ferroptosis as a secondary injuries of ACNSIs. In recent studies, anti-ferroptosis agents such as the ferroptosis inhibitor Ferrostain-1 and iron chelation therapy have shown potential in ameliorating the deleterious effects of ferroptosis in cases of traumatic ACNSI. The importance of this evidence is extremely significant in relation to the research and control of ACNSIs. Therefore, our review aims to provide researchers focusing on enhancing the therapeutic outcomes of ACNSIs with valuable insights by summarizing the physiopathological mechanisms of ACNSIs and exploring the correlation between ferroptosis, mitochondrial dysfunction, and ACNSIs.
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Affiliation(s)
- Wenxue Dong
- Department of Neurosurgery, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Fanghe Gong
- Department of Neurosurgery, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Yu Zhao
- School of Medicine, Xizang Minzu University, Xianyang, China
| | - Hongmin Bai
- Department of Neurosurgery, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Ruixin Yang
- Department of Neurosurgery, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
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Haupenthal D, Schwab S, Kuramatsu JB. Hematoma expansion in intracerebral hemorrhage - the right target? Neurol Res Pract 2023; 5:36. [PMID: 37496094 PMCID: PMC10373350 DOI: 10.1186/s42466-023-00256-6] [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: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND The avoidance of hematoma expansion is the most important therapeutic goal during acute care of patients with intracerebral hemorrhage. Hematoma expansion occurs in up to 20-40% of patients and leads to poorer patient outcome in one of the most severe sub-types of stroke. MAIN TEXT At current, randomized controlled trials have failed to provide evidence for interventions that effectively improve functional outcome in patients with intracerebral hemorrhage. Hence, hematoma expansion may serve as important surrogate target that appears causally linked with a poorer prognosis. Therefore, reduction of hematoma expansion rates will eventually translate to improved patient outcome overall. Recent years have shed light on the importance of early and aggressive treatment in order to reduce the risk for hematoma expansion in these patients. Time measures and imaging markers have been identified that may allow patient selection at very high risk for hematoma expansion. CONCLUSIONS Refinements in patient selection may increase chance for randomized trials to show true benefit. Therefore, this current review article will critically evaluate and discuss available evidence associated with hematoma expansion in patients with intracerebral hemorrhage.
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Affiliation(s)
- David Haupenthal
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
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Sundaresan V, Arthofer C, Zamboni G, Murchison AG, Dineen RA, Rothwell PM, Auer DP, Wang C, Miller KL, Tendler BC, Alfaro-Almagro F, Sotiropoulos SN, Sprigg N, Griffanti L, Jenkinson M. Automated detection of cerebral microbleeds on MR images using knowledge distillation framework. Front Neuroinform 2023; 17:1204186. [PMID: 37492242 PMCID: PMC10363739 DOI: 10.3389/fninf.2023.1204186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/19/2023] [Indexed: 07/27/2023] Open
Abstract
Introduction Cerebral microbleeds (CMBs) are associated with white matter damage, and various neurodegenerative and cerebrovascular diseases. CMBs occur as small, circular hypointense lesions on T2*-weighted gradient recalled echo (GRE) and susceptibility-weighted imaging (SWI) images, and hyperintense on quantitative susceptibility mapping (QSM) images due to their paramagnetic nature. Accurate automated detection of CMBs would help to determine quantitative imaging biomarkers (e.g., CMB count) on large datasets. In this work, we propose a fully automated, deep learning-based, 3-step algorithm, using structural and anatomical properties of CMBs from any single input image modality (e.g., GRE/SWI/QSM) for their accurate detections. Methods In our method, the first step consists of an initial candidate detection step that detects CMBs with high sensitivity. In the second step, candidate discrimination step is performed using a knowledge distillation framework, with a multi-tasking teacher network that guides the student network to classify CMB and non-CMB instances in an offline manner. Finally, a morphological clean-up step further reduces false positives using anatomical constraints. We used four datasets consisting of different modalities specified above, acquired using various protocols and with a variety of pathological and demographic characteristics. Results On cross-validation within datasets, our method achieved a cluster-wise true positive rate (TPR) of over 90% with an average of <2 false positives per subject. The knowledge distillation framework improves the cluster-wise TPR of the student model by 15%. Our method is flexible in terms of the input modality and provides comparable cluster-wise TPR and better cluster-wise precision compared to existing state-of-the-art methods. When evaluating across different datasets, our method showed good generalizability with a cluster-wise TPR >80 % with different modalities. The python implementation of the proposed method is openly available.
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Affiliation(s)
- Vaanathi Sundaresan
- Department of Computational and Data Sciences, Indian Institute of Science, Bengaluru, Karnataka, India
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Christoph Arthofer
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health and Care Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Giovanna Zamboni
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Dipartimento di Scienze Biomediche, Metaboliche e Neuroscienze, Universitá di Modena e Reggio Emilia, Modena, Italy
| | - Andrew G. Murchison
- Department of Neuroradiology, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Robert A. Dineen
- National Institute for Health and Care Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
- Radiological Sciences, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Peter M. Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Dorothee P. Auer
- National Institute for Health and Care Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
- Radiological Sciences, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Chaoyue Wang
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Karla L. Miller
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Benjamin C. Tendler
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Fidel Alfaro-Almagro
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Stamatios N. Sotiropoulos
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health and Care Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Ludovica Griffanti
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Human Brain Activity, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Mark Jenkinson
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Australian Institute for Machine Learning, School of Computer Science, The University of Adelaide, Adelaide, SA, Australia
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Song L, Chen X. Trials in intracerebral haemorrhage: a path to success? Lancet Neurol 2023; 22:542-543. [PMID: 37353268 DOI: 10.1016/s1474-4422(23)00201-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Lili Song
- The George Institute for Global Health China, Beijing 100600, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Woodhouse LJ, Craig J, Krishnan K, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for patients with spontaneous intracerebral haemorrhage taking antiplatelet drugs (DASH): a UK-based, phase 2, randomised, placebo-controlled, multicentre feasibility trial. Lancet Neurol 2023; 22:557-567. [PMID: 37353276 PMCID: PMC10284719 DOI: 10.1016/s1474-4422(23)00157-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The risk of death from spontaneous intracerebral haemorrhage is increased for people taking antiplatelet drugs. We aimed to assess the feasibility of randomising patients on antiplatelet drug therapy with spontaneous intracerebral haemorrhage to desmopressin or placebo to reduce the antiplatelet drug effect. METHODS DASH was a phase 2, randomised, placebo-controlled, multicentre feasibility trial. Patients were recruited from ten acute stroke centres in the UK and were eligible if they had an intracerebral haemorrhage with stroke symptom onset within 24 h of randomisation, were aged 18 years or older, and were taking an antiplatelet drug. Participants were randomly assigned (1:1) to a single dose of intravenous desmopressin 20 μg or matching placebo. Treatment allocation was concealed from all staff and patients involved in the trial. The primary outcome was feasibility, which was measured as the number of eligible patients randomised and the proportion of eligible patients approached, and analysis was by intention to treat. The trial was prospectively registered with ISRCTN (reference ISRCTN67038373), and it is closed to recruitment. FINDINGS Between April 1, 2019, and March 31, 2022, 1380 potential participants were screened for eligibility. 176 (13%) participants were potentially eligible, of whom 57 (32%) were approached, and 54 (31%) consented and were subsequently recruited and randomly assigned to receive desmopressin (n=27) or placebo (n=27). The main reason for eligible patients not being recruited was the patient arriving out of hours (74 [61%] of 122 participants). The recruitment rate increased after the enrolment period was extended from 12 h to 24 h, but it was then impaired due to the COVID-19 pandemic. Of the 54 participants included in the analysis (mean age 76·4 years [SD 11·3]), most were male (36 [67%]) and White (50 [93%]). 53 (98%) of 54 participants received all of their allocated treatment (one participant assigned desmopressin only received part of the infusion). No participants were lost to follow-up or withdrew from the trial. Death or dependency on others for daily activities at day 90 (modified Rankin Scale score >4) occurred in six (22%) of 27 participants in the desmopressin group and ten (37%) of 27 participants in the placebo group. Serious adverse events occurred in 12 (44%) participants in the desmopressin group and 13 (48%) participants in the placebo group. The most common adverse events were expansion of the haemorrhagic stroke (four [15%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group) and pneumonia (one [4%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group). INTERPRETATION Our results show it is feasible to randomise patients with spontaneous intracerebral haemorrhage who are taking antiplatelet drugs to desmopressin or placebo. Our findings support the need for a definitive trial to determine if desmopressin improves outcomes in patients with intracerebral haemorrhage on antiplatelet drug therapy. FUNDING National Institute for Health Research.
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Affiliation(s)
- Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Diane Havard
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Jennifer Craig
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Tim J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Mental Health and Clinical Neurosciences, and Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Woodhouse LJ, Appleton JP, Ankolekar S, England TJ, Mair G, Muir K, Price CI, Pocock S, Randall M, Robinson TG, Roffe C, Sandset EC, Saver JL, Siriwardena AN, Sprigg N, Wardlaw JM, Bath PM. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial. BMJ Neurol Open 2023; 5:e000424. [PMID: 37564156 PMCID: PMC10410995 DOI: 10.1136/bmjno-2023-000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/11/2023] [Indexed: 08/12/2023] Open
Abstract
Background The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation. Methods RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS). Results 1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84). Conclusion At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH. Trial registration number ISRCTN26986053.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sandeep Ankolekar
- Department of Neurology, King's College Hospital NHS Trust, London, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and GEM, Royal Derby Hospital, Derby, UK
| | - Grant Mair
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Keith Muir
- Neurology, University of Glasgow, Glasgow, UK
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, and NIHR Biomedical Research Unit for Cardiovascular Diseases, University of Leicester, Leicester, UK
| | - Christine Roffe
- Institute for Science and Technology in Medicine, Keele University, Keele, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Appleton JP, Law ZK, Woodhouse LJ, Al-Shahi Salman R, Beridze M, Christensen H, Dineen RA, Guerrero JJE, England TJ, Karlinski M, Krishnan K, Laska AC, Lyrer P, Ozturk S, Roffe C, Roberts I, Robinson TG, Scutt P, Werring DJ, Bath PM, Sprigg N. Effects of blood pressure and tranexamic acid in spontaneous intracerebral haemorrhage: a secondary analysis of a large randomised controlled trial. BMJ Neurol Open 2023; 5:e000423. [PMID: 37337529 PMCID: PMC10277112 DOI: 10.1136/bmjno-2023-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
Background Tranexamic acid reduced haematoma expansion and early death, but did not improve functional outcome in the tranexamic acid for hyperacute spontaneous intracerebral haemorrhage-2 (TICH-2) trial. In a predefined subgroup, there was a statistically significant interaction between prerandomisation baseline systolic blood pressure (SBP) and the effect of tranexamic acid on functional outcome (p=0.019). Methods TICH-2 was an international prospective double-blind placebo-controlled randomised trial evaluating intravenous tranexamic acid in patients with acute spontaneous intracerebral haemorrhage (ICH). Prerandomisation baseline SBP was split into predefined ≤170 and >170 mm Hg groups. The primary outcome at day 90 was the modified Rankin Scale (mRS), a measure of dependency, analysed using ordinal logistic regression. Haematoma expansion was defined as an increase in haematoma volume of >33% or >6 mL from baseline to 24 hours. Data are OR or common OR (cOR) with 95% CIs, with significance at p<0.05. Results Of 2325 participants in TICH-2, 1152 had baseline SBP≤170 mm Hg and were older, had larger lobar haematomas and were randomised later than 1173 with baseline SBP>170 mm Hg. Tranexamic acid was associated with a favourable shift in mRS at day 90 in those with baseline SBP≤170 mm Hg (cOR 0.73, 95% CI 0.59 to 0.91, p=0.005), but not in those with baseline SBP>170 mm Hg (cOR 1.05, 95% CI 0.85 to 1.30, p=0.63). In those with baseline SBP≤170 mm Hg, tranexamic acid reduced haematoma expansion (OR 0.62, 95% CI 0.47 to 0.82, p=0.001), but not in those with baseline SBP>170 mm Hg (OR 1.02, 95% CI 0.77 to 1.35, p=0.90). Conclusions Tranexamic acid was associated with improved clinical and radiological outcomes in ICH patients with baseline SBP≤170 mm Hg. Further research is needed to establish whether certain subgroups may benefit from tranexamic acid in acute ICH. Trial registration number ISRCTN93732214.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Neurology Unit, Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Lisa Jane Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | | | - Maia Beridze
- The First University Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Juan José Egea Guerrero
- Neurocritical Care Unit, Virgen del Rocio University Hospital, Sevilla, Spain
- IbiS, CSIC, University of Seville, Sevilla, Spain
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Michal Karlinski
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Philippe Lyrer
- Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
| | - Serefnur Ozturk
- Neurology, Faculty of Medicine, Selcuk Universitesi, Konya, Turkey
| | - Christine Roffe
- Stroke Research, School of Medicine, University of Keele, Stoke-on-Trent, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Polly Scutt
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Philip M Bath
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
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Teo KC, Fong SM, Leung WCY, Leung IYH, Wong YK, Choi OMY, Yam KK, Lo RCN, Cheung RTF, Ho SL, Tsang ACO, Leung GKK, Chan KH, Lau KK. Location-Specific Hematoma Volume Cutoff and Clinical Outcomes in Intracerebral Hemorrhage. Stroke 2023; 54:1548-1557. [PMID: 37216445 DOI: 10.1161/strokeaha.122.041246] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Major intracerebral hemorrhage (ICH) trials have largely been unable to demonstrate therapeutic benefit in improving functional outcomes. This may be partly due to the heterogeneity of ICH outcomes based on their location, where a small strategic ICH could be debilitating, thus confounding therapeutic effects. We aimed to determine the ideal hematoma volume cutoff for different ICH locations in predicting ICH outcomes. METHODS We retrospectively analyzed consecutive ICH patients enrolled in the University of Hong Kong prospective stroke registry from January 2011 to December 2018. Patients with premorbid modified Rankin Scale score >2 or who underwent neurosurgical intervention were excluded. ICH volume cutoff, sensitivity, and specificity in predicting respective 6-month neurological outcomes (good [modified Rankin Scale score 0-2], poor [modified Rankin Scale score 4-6], and mortality) for specific ICH locations were determined using receiver operating characteristic curves. Separate multivariate logistic regression models were also conducted for each location-specific volume cutoff to determine whether these cutoffs were independently associated with respective outcomes. RESULTS Among 533 ICHs, the volume cutoff for good outcome according to ICH location was 40.5 mL for lobar, 32.5 mL for putamen/external capsule, 5.5 mL for internal capsule/globus pallidus, 6.5 mL for thalamus, 17 mL for cerebellum, and 3 mL for brainstem. ICH smaller than the cutoff for all supratentorial sites had higher odds of good outcomes (all P<0.05). Volumes exceeding 48 mL for lobar, 41 mL for putamen/external capsule, 6 mL for internal capsule/globus pallidus, 9.5 mL for thalamus, 22 mL for cerebellum, and 7.5 mL for brainstem were at greater risk of poor outcomes (all P<0.05). Mortality risks were significantly higher for volumes that exceeded 89.5 mL for lobar, 42 mL for putamen/external capsule, and 21 mL for internal capsule/globus pallidus (all P<0.001). All receiver operating characteristic models for location-specific cutoffs had good discriminant values (area under the curve >0.8), except in predicting good outcome for cerebellum. CONCLUSIONS ICH outcomes differed with location-specific hematoma size. Location-specific volume cutoff should be considered in patient selection for ICH trials.
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Affiliation(s)
- Kay-Cheong Teo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Sze-Man Fong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - William C Y Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ian Y H Leung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Olivia M Y Choi
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Ka-Keung Yam
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Rachel C N Lo
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Raymond T F Cheung
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Shu-Leong Ho
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Anderson C O Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Gilberto K K Leung
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Koon-Ho Chan
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- Research Center of Heart, Brain, Hormone and Healthy Aging (R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR (R.T.F.C., K.-H.C., K.-K.L.)
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