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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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Landman TRJ, Schoon Y, Warlé MC, Meijer FJA, Leeuw FED, Thijssen DHJ. The effect of repeated remote ischemic postconditioning after an ischemic stroke (REPOST): A randomized controlled trial. Int J Stroke 2023; 18:296-303. [PMID: 35593677 PMCID: PMC9941800 DOI: 10.1177/17474930221104710] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS A potential strategy to treat ischemic stroke may be the application of repeated remote ischemic postconditioning (rIPostC). This consists of several cycles of brief periods of limb ischemia followed by reperfusion, which can be applied by inflating a simple blood pressure cuff and subsequently could result in neuroprotection after stroke. METHODS Adult patients admitted with an ischemic stroke in the past 24 h were randomized 1:1 to repeated rIPostC or sham-conditioning. Repeated rIPostC was performed by inflating a blood pressure cuff around the upper arm (4 × 5 min at 200 mm Hg), which was repeated twice daily during hospitalization with a maximum of 4 days. Primary outcome was infarct size after 4 days or at discharge. Secondary outcomes included the modified Rankin Scale (mRS)-score after 12 weeks and the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The trial was preliminarily stopped after we included 88 of the scheduled 180 patients (average age: 70 years, 68% male) into rIPostC (n = 40) and sham-conditioning (n = 48). Median infarct volume was 2.19 mL in rIPostC group and 5.90 mL in sham-conditioning, which was not significantly different between the two groups (median difference: 3.71; 95% CI: -0.56 to 6.09; p = 0.31). We found no significant shift in the mRS score distribution between groups. The adjusted common odds ratio was 2.09 (95% CI: 0.88-5.00). We found no significant difference in the NIHSS score between groups (median difference: 1.00; 95% CI: -0.99 to 1.40; p = 0.51). CONCLUSION This study found no significant improvement in infarct size or clinical outcome in patients with an acute ischemic stroke who were treated with repeated remote ischemic postconditioning. However, due to a lower-than-expected inclusion rate, no definitive conclusions about the effectiveness of rIPostC can be drawn.
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Affiliation(s)
- Thijs RJ Landman
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands,Thijs RJ Landman, Department of Physiology,
Radboud Institute for Health Sciences, Radboud University Medical Center, Geert
Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine,
Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frederick JA Meijer
- Department of Medical Imaging, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frank-Erik De Leeuw
- Donders Center for Medical
Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Dick HJ Thijssen
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
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Saffari SE, Ning Y, Xie F, Chakraborty B, Volovici V, Vaughan R, Ong MEH, Liu N. AutoScore-Ordinal: an interpretable machine learning framework for generating scoring models for ordinal outcomes. BMC Med Res Methodol 2022; 22:286. [PMID: 36333672 PMCID: PMC9636613 DOI: 10.1186/s12874-022-01770-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background Risk prediction models are useful tools in clinical decision-making which help with risk stratification and resource allocations and may lead to a better health care for patients. AutoScore is a machine learning–based automatic clinical score generator for binary outcomes. This study aims to expand the AutoScore framework to provide a tool for interpretable risk prediction for ordinal outcomes. Methods The AutoScore-Ordinal framework is generated using the same 6 modules of the original AutoScore algorithm including variable ranking, variable transformation, score derivation (from proportional odds models), model selection, score fine-tuning, and model evaluation. To illustrate the AutoScore-Ordinal performance, the method was conducted on electronic health records data from the emergency department at Singapore General Hospital over 2008 to 2017. The model was trained on 70% of the data, validated on 10% and tested on the remaining 20%. Results This study included 445,989 inpatient cases, where the distribution of the ordinal outcome was 80.7% alive without 30-day readmission, 12.5% alive with 30-day readmission, and 6.8% died inpatient or by day 30 post discharge. Two point-based risk prediction models were developed using two sets of 8 predictor variables identified by the flexible variable selection procedure. The two models indicated reasonably good performance measured by mean area under the receiver operating characteristic curve (0.758 and 0.793) and generalized c-index (0.737 and 0.760), which were comparable to alternative models. Conclusion AutoScore-Ordinal provides an automated and easy-to-use framework for development and validation of risk prediction models for ordinal outcomes, which can systematically identify potential predictors from high-dimensional data.
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Hong JM, Lee JS, Lee YB, Shin DH, Shin DI, Hwang YH, Ahn SH, Kim JG, Sohn SI, Kwon SU, Lee JS, Gwag BJ, Chamorro Á, Choi DW. Nelonemdaz for Patients With Acute Ischemic Stroke Undergoing Endovascular Reperfusion Therapy: A Randomized Phase II Trial. Stroke 2022; 53:3250-3259. [PMID: 36065810 PMCID: PMC9586831 DOI: 10.1161/strokeaha.122.039649] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/01/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nelonemdaz is a multitarget neuroprotectant that selectively blocks N-methyl-D-aspartate receptors and scavenges free radicals, as proven in preclinical ischemia-reperfusion studies. We aimed to evaluate the safety and efficacy of nelonemdaz in patients with acute ischemic stroke receiving endovascular reperfusion therapy. METHODS This phase II randomized trial involved participants with large-artery occlusion in the anterior circulation at baseline who received endovascular reperfusion therapy <8 hours from symptom onset at 7 referral stroke centers in South Korea between October 29, 2016, and June 1, 2020. Two hundred thirteen patients were screened and 209 patients were randomly assigned at a 1:1:1 ratio using a computer-generated randomization system. Patients were divided into 3 groups based on the medication received-placebo, low-dose (2750 mg) nelonemdaz, and high-dose (5250 mg) nelonemdaz. The primary outcome was the proportion of patients with modified Rankin Scale scores of 0-2 at 12 weeks. RESULTS Two hundred eight patients were assigned to the placebo (n=70), low-dose (n=71), and high-dose (n=67) groups. The groups had similar baseline characteristics. The primary outcome was achieved in 183 patients, and it did not differ among the groups (33/61 [54.1%], 40/65 [61.5%], and 36/57 [63.2%] patients; P=0.5578). The common odds ratio (90% CI) indicating a favorable shift in the modified Rankin Scale scores at 12 weeks was 1.55 (0.92-2.60) between the placebo and low-dose groups and 1.61 (0.94-2.76) between the placebo and high-dose groups. No serious adverse events were reported. CONCLUSIONS The study arms showed no significant difference in the proportion of patients achieving modified Rankin Scale scores of 0-2 at 12 weeks. Nevertheless, nelonemdaz-treated patients showed a favorable tendency toward achieving these scores at 12 weeks, without serious adverse effects. Thus, a large-scale phase III trial is warranted. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT02831088.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, Republic of Korea (J.M.H., Jin Soo Lee)
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, Republic of Korea (J.M.H., Jin Soo Lee)
| | - Yeong-Bae Lee
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Republic of Korea (Y.-B.L., D.H.S.)
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Republic of Korea (Y.-B.L., D.H.S.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea (D.-I.S.)
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea (Y.-H.H.)
| | - Seong Hwan Ahn
- Department of Neurology, College of Medicine, Chosun University, Gwangju, Republic of Korea (S.H.A.)
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Republic of Korea (J.G.K.)
| | - Sung-Il Sohn
- Department of Neurology, Dongsan Medical Center, Keimyung University, Daegu, Republic of Korea (S.-I.S.)
| | - Sun U. Kwon
- Department of Neurology (S.U.K.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center (Ji Sung Lee), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byoung Joo Gwag
- Department of Biotechnology, College of Life Science and Biotechnology, Yonsei University, Seoul, Republic of Korea (B.J.G.)
| | - Ángel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Spain (A.C.)
| | - Dennis W. Choi
- Department of Neurology, Stony Brook University, NY (D.W.C.)
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Eltoft A, Wilsgaard T, Roaldsen MB, Søyland MH, Lundström E, Petersson J, Indredavik B, Putaala J, Christensen H, Kõrv J, Jatužis D, Engelter ST, De Marchis GM, Werring DJ, Robinson T, Tveiten A, Mathiesen EB. Statistical analysis plan for the randomized controlled trial Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST). Trials 2022; 23:421. [PMID: 35590386 PMCID: PMC9118782 DOI: 10.1186/s13063-022-06301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with wake-up ischemic stroke are frequently excluded from thrombolytic treatment due to unknown symptom onset time and limited availability of advanced imaging modalities. The Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST) is a randomized controlled trial of intravenous tenecteplase 0.25 mg/kg and standard care versus standard care alone (no thrombolysis) in patients who wake up with acute ischemic stroke and can be treated within 4.5 h of wakening based on non-contrast CT findings. OBJECTIVE To publish the detailed statistical analysis plan for TWIST prior to unblinding. METHODS The TWIST statistical analysis plan is consistent with the Consolidating Standard of Reporting Trials (CONSORT) statement and provides clear and open reporting. DISCUSSION Publication of the statistical analysis plan serves to reduce potential trial reporting bias and clearly outlines the pre-specified analyses. TRIAL REGISTRATION ClinicalTrials.gov NCT03181360 . EudraCT Number 2014-000096-80 . WHO ICRTP registry number ISRCTN10601890 .
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Affiliation(s)
- Agnethe Eltoft
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway. .,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Melinda B Roaldsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Mary-Helen Søyland
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Bent Indredavik
- Department of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu and Tartu University Hospital, Tartu, Estonia
| | - Dalius Jatužis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Thompson Robinson
- College of Life Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Arnstein Tveiten
- Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Ellisiv B Mathiesen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Tokunboh I, Sung EM, Chatfield F, Gaines N, Nour M, Starkman S, Saver JL. Improving Visualization Methods of Utility-Weighted Disability Outcomes for Stroke Trials. Front Neurol 2022; 13:875350. [PMID: 35645952 PMCID: PMC9136165 DOI: 10.3389/fneur.2022.875350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background The modified Rankin Scale (mRS) is the most common endpoint in acute stroke trials, but its power is limited when analyzed dichotomously and its indication of effect size is challenging to interpret when analyzed ordinally. To address these issues, the utility-weighted-mRS (UW-mRS) has been developed as a patient-centered, linear scale. However, appropriate data visualizations of UW-mRS results are needed, as current stacked bar chart displays do not convey crucial utility-weighting information. Design/Methods Two UW-mRS display formats were devised: (1) Utility Staircase charts, and (2) choropleth-stacked-bar-charts (CSBCs). In Utility Staircase displays, mRS segment height reflects the utility value of each mRS level. In CSBCs, mRS segment color intensity reflects the utility of each mRS level. Utility Staircase and CSBC figures were generated for 15 randomized comparisons of acute ischemic/hemorrhagic stroke therapies, including fibrinolysis, endovascular reperfusion, blood pressure moderation, and hemicraniectomy. Display accuracy in showing utility outcomes was assessed with the Tufte-lie-factor and ease-of-use assessed by formal ratings completed by a panel of 4 neurologists and emergency physicians and one nurse-coordinator. Results The Utility Staircase and CSBC displays rapidly conveyed patient-centered valuation of trial outcome distributions not available in conventional ordinal stacked bar charts. Tufte-lie-factor (LF) scores indicated "substantial distortion" of utility-valued outcomes for 93% (14/15) of conventional stacked bar charts, vs. "no distortion" for all Utility Staircase and CSBC displays. Clinician ratings on the Figural Display Questionnaire indicated that utility information encoded in row height (Utility Staircase display) was more readily assimilated than that conveyed in segment hue intensity (CSBC), both superior to conventional stacked bar charts. Conclusions Utility Staircase displays are an efficient graphical format for conveying utility weighted-modified Rankin Scale primary endpoint results of acute stroke trials, and choropleth-stacked-bar-charts a good alternative. Both are more accurate in depicting quantitative, health-related quality of life results and preferred by clinician users for utility results visualization, compared with conventional stacked bar charts.
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Affiliation(s)
- Ivie Tokunboh
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Eleanor Mina Sung
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States
| | - Fiona Chatfield
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nathan Gaines
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - May Nour
- Department of Neurology, Division of Interventional Neuroradiology, and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Sidney Starkman
- Departments of Emergency Medicine and Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Pérez de la Ossa N, Abilleira S, Jovin TG, García-Tornel Á, Jimenez X, Urra X, Cardona P, Cocho D, Purroy F, Serena J, San Román Manzanera L, Vivanco-Hidalgo RM, Salvat-Plana M, Chamorro A, Gallofré M, Molina CA, Cobo E, Davalos A, Ribo M. Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial. JAMA 2022; 327:1782-1794. [PMID: 35510397 PMCID: PMC9073661 DOI: 10.1001/jama.2022.4404] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Natalia Pérez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Tudor G. Jovin
- Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | - Álvaro García-Tornel
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Xavier Jimenez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Dolores Cocho
- Neurology Department, Hospital Granollers, Granollers, Spain
| | - Francisco Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joaquin Serena
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, Girona, Spain
| | | | - Rosa Maria Vivanco-Hidalgo
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Plana
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Angel Chamorro
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Miquel Gallofré
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Carlos A. Molina
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Erik Cobo
- Statistics and Operational Research, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Antoni Davalos
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marc Ribo
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
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8
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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9
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Akhtar N, Singh R, Kamran S, Babu B, Sivasankaran S, Joseph S, Morgan D, Shuaib A. Diabetes: Chronic Metformin Treatment and Outcome Following Acute Stroke. Front Neurol 2022; 13:849607. [PMID: 35557626 PMCID: PMC9087832 DOI: 10.3389/fneur.2022.849607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Aim To evaluate if in patients with known diabetes, pretreatment metformin will lead to less severe stroke, better outcome, and lower mortality following acute stroke. Methods The Qatar stroke database was interrogated for stroke severity and outcome in patients with ischemic stroke. Outcome was compared in nondiabetic vs. diabetic patients and in diabetic patients on metformin vs. other hypoglycemic agents. The National Institute of Health Stroke Scale was used to measure stroke severity and 90-day modified Rankin scale (mRS) score to determine outcome following acute stroke. Results In total, 4,897 acute stroke patients [nondiabetic: 2,740 (56%) and diabetic: 2,157 (44%)] were evaluated. There were no significant differences in age, risk factors, stroke severity and type, or thrombolysis between the two groups. At 90 days, mRS (shift analysis) showed significantly poor outcome in diabetic patients (p < 0.001) but no differences in mortality. In the diabetic group, 1,132 patients were on metformin and 1,025 on other hypoglycemic agents. mRS shift analysis showed a significantly better outcome in metformin-treated patients (p < 0.001) and lower mortality (8.1 vs. 4.6% p < 0.001). Multivariate negative binomial analyses showed that the presence of diabetes negatively affected the outcome (90-day mRS) by factor 0.17 (incidence risk ratio, IRR, 1.17; CI [1.08-1.26]; p < 0.001) when all independent variables were held constant. In diabetic patients, pre-stroke treatment with metformin improved the outcome (90-day mRS) by factor 0.14 (IRR 0.86 [CI 0.75-0.97] p = 0.006). Conclusion Similar to previous reports, our study shows that diabetes adversely affects stroke outcome. The use of prior metformin is associated with better outcome in patients with ischemic stroke and results in lower mortality. The positive effects of metformin require further research to better understand its mechanism.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Cardiology Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Blessy Babu
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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10
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Collateral Status and Clinical Outcomes after Mechanical Thrombectomy in Patients with Anterior Circulation Occlusion. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7796700. [PMID: 35126946 PMCID: PMC8808144 DOI: 10.1155/2022/7796700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022]
Abstract
Background. Successful mechanical thrombectomy (MT) requires reliable, noninvasive selection criteria. We aimed to investigate the association of collateral status and clinical outcomes after MT in patients with ischemic stroke due to anterior circulation occlusion. Methods. 109 patients with poor collaterals and 110 aged, sex-matched patients with good collaterals were enrolled in the study. Collateral circulation was estimated by the CT angiography with a 0–3 scale. The collateral status was categorized as poor collaterals (scores 0–1) and good collaterals (scores 2-3). The reperfusion was assessed by the modified Treatment in Cerebral Infarction scale (mTICI, score 0/1/2a/2b/3). The clinical outcomes included the scores on the modified Rankin scale (mRS, ranging from 0 to 6) and death 90 days after mechanical thrombectomy. Results. Patients with greater scores of collateral status were more likely to achieve successful reperfusion (mTICI 2b/3). Patients with good collaterals were significantly associated with a higher chance of achieving mRS of 0–1 at 90 days (adjusted ORs: 4.55; 95% CI: 3.17–7.24; and
< 0.001) and a lower risk of death at 90 days (adjusted ORs: 0.87; 95% CI: 4.0%–28.0%; and
= 0.012) compared to patients with poor collaterals. In subgroup analyses, patients with statin use seem to benefit more from the effect of collateral status on good mRS (≤2). Conclusion. Among patients with acute ischemic stroke caused by anterior circulation occlusion, better collateral status is associated with higher scores on mRS and lower mortality after mechanical thrombectomy. Statin use might have an interaction with the effect of collateral status.
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11
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Howard CW, Zou G, Morrow SA, Fridman S, Racosta JM. Wilcoxon-Mann-Whitney odds ratio: A statistical measure for ordinal outcomes such as EDSS. Mult Scler Relat Disord 2022; 59:103516. [PMID: 35123291 DOI: 10.1016/j.msard.2022.103516] [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: 09/28/2021] [Revised: 12/13/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In many clinical situations, ordinal scales afford the primary method of semi-quantifying patient outcomes. In the field of multiple sclerosis, the primary ordinal scale is the Expanded Disability Status Scale. Predominant methods of ordinal scale statistical analysis provide a p-value without effect size or rely heavily on the assumption of proportionality of odds, subjecting them to lack of power and error. The Wilcoxon-Manny-Whitney Odds is a statistical method which provides significant information such as p-value, effect size, number needed to treat, confidence intervals, and is largely assumption-free. However, its utility has not been demonstrated in the field of multiple sclerosis. METHODS Three clinical studies in the field of multiple sclerosis were selected which utilized ordinal scale outcomes at group or individual levels. Data from these studies was extracted using WebPlotDigitizer, and a custom Wilxocon-Mann-Whitney Odds software was applied to each dataset to re-analyze the main outcomes of the studies. RESULTS Re-analysis of the manuscript by Muraro et al., 2017 demonstrated that autologous stem cell transplantation for relapsing remitting multiple sclerosis resulted in a 65% chance of improving from any Expanded Disability Status Scale category, although not significant. Re-analysis of the manuscript by Songthammawat et al., 2019 demonstrated chance of improvement with intravenous methylprednisolone and concurrent plasma exchange was 185% versus 32% in intravenous methylprednisolone with add-on plasma exchange, although not significant. Re-analysis of Kister et al., 2012 demonstrated the chances of mobility or cognition scores generally favored decline at every 5-year increment of study, and although statistically significant, these were smaller effect sizes ranging from an 11% chance of improvement to a 66% chance of decline over a 5-year interval. DISCUSSION The Wilcoxon-Mann-Whitney Odds simplifies ordinal data analysis with its robust largely assumption-free nature. In the place of numerous statistical tests, this single test provides effect size estimate, number needed to treat, p-values, and confidence intervals. Importantly, the Wilcoxon-Mann-Whitney Odds effect size calculation is intuitively applicable to both individual and population-levels. Further, the Wilcoxon-Mann-Whitney Odds allows intuitive description of the progression of large cohorts over time, and we were able to clearly convey the odds of mobility and cognitive decline over 30 years in a large multiple sclerosis cohort. Overall, the Wilcoxon-Mann-Whitney Odds is a powerful and robust statistical test with significant promise within the field of multiple sclerosis.
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Affiliation(s)
- C W Howard
- Section of Neurology, Department of Internal Medicine, University of Manitoba, Manitoba, Canada.
| | - G Zou
- Dept of Epidemiology and Biostatistics, Western University, London, Canada; Robarts Research Institute, Western University, London, Canada
| | - S A Morrow
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - S Fridman
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - J M Racosta
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; The London MS Epidemiology Laboratory. London, Ontario, Canada
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12
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Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Bala F, Bricout N, Nouri N, Cordonnier C, Henon H, Casolla B. Safety and outcomes of endovascular treatment in patients with very severe acute ischemic stroke. J Neurol 2021; 269:2493-2502. [PMID: 34618225 DOI: 10.1007/s00415-021-10807-z] [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: 06/15/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with anterior circulation ischemic strokes due to large vessel occlusion (AIS-LVO) and very severe neurological deficits (National Institutes of Health Stroke Scale (NIHSS) score > 25) were under-represented in clinical trials on endovascular treatment (EVT). We aimed to evaluate safety and outcomes of EVT in patients with very severe vs. severe (NIHSS score 15-25) neurological deficits. METHODS We included consecutive patients undergoing EVT for AIS-LVO between January 2015 and December 2019 at Lille University Hospital. We compared rates of parenchymal hemorrhage (PH), symptomatic intracranial hemorrhage (SICH), procedural complications, and 90-day mortality between patients with very severe vs. severe neurological deficit using univariable and multivariable logistic regression analyses. Functional outcome (90-days modified Rankin Scale) was compared between groups using ordinal logistic regression analysis. RESULTS Among 1484 patients treated with EVT, 108 (7%) had pre-treatment NIHSS scores > 25, 873 (59%) with NIHSS scores 15-25 and 503 (34%) with NIHSS scores < 15. Rates of PH, SICH, successful recanalization, and procedural complications were similar in patients with NIHSS scores > 25 and NIHSS 15-25. Patients with NIHSS > 25 had a lower likelihood of improved functional outcome (adjcommon OR 0.31[95% CI 0.21-0.47]) and higher odds of mortality at 90 days (adjOR 2.3 [95% CI 1.5-3.7]) compared to patients with NIHSS 15-25. Successful recanalization was associated with better functional outcome (adjcommon OR 3.8 [95% CI 1.4-10.4]), and lower odds of mortality (adjOR 0.3 [95% CI 0.1-0.9]) in patients with very severe stroke. The therapeutic effect of recanalization on functional outcome and mortality was similar in both groups. CONCLUSIONS In patients with very severe neurological deficit, EVT was safe and successful recanalization was strongly associated with better functional outcome at 90 days.
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Affiliation(s)
- Fouzi Bala
- Department of Interventional Neuroradiology, CHU Lille, 59000, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, CHU Lille, 59000, Lille, France
| | - Nasreddine Nouri
- Department of Interventional Neuroradiology, CHU Lille, 59000, Lille, France
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience and Cognition, F-59000, Lille, France
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience and Cognition, F-59000, Lille, France.
| | - Barbara Casolla
- Univ. Lille, Inserm, CHU Lille, U1172-LilNCog-Lille Neuroscience and Cognition, F-59000, Lille, France
- Department of Neurology, Stroke Unit, Univ. Côte d'Azur (UCA), CHU Nice, URRIS, Unité de Recherche Clinique Cote d'Azur-UR2CA, Nice, France
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15
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Pohjola A, Oulasvirta E, Roine RP, Sintonen HP, Hafez A, Koroknay-Pál P, Lehto H, Niemelä M, Laakso A. Comparing health-related quality of life in modified Rankin Scale grades: 15D results from 323 patients with brain arteriovenous malformation and population controls. Acta Neurochir (Wien) 2021; 163:2037-2046. [PMID: 33860377 PMCID: PMC8195799 DOI: 10.1007/s00701-021-04847-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
Background We wanted to understand how patients with different modified Rankin Scale (mRS) grades differ regarding their health-related quality of life (HRQoL) and how this affects the interpretation and dichotomization of the grade. Methods In 2016, all adult patients in our brain arteriovenous malformation (AVM) database (n = 432) were asked to fill in mailed letters including a questionnaire about self-sufficiency and lifestyle and the 15D HRQoL questionnaire. The follow-up mRS was defined in 2016 using the electronic patient registry and the questionnaire data. The 15D profiles of each mRS grade were compared to those of the general population and to each other, using ANCOVA with age and sex standardization. Results Patients in mRS 0 (mean 15D score = 0.954 ± 0.060) had significantly better HRQoL than the general population (mean = 0.927 ± 0.028), p < 0.0001, whereas patients in mRS 1–4 had worse HRQoL than the general population, p < 0.0001. Patients in mRS 1 (mean = 0.844 ± 0.100) and mRS 2 (mean = 0.838 ± 0.107) had a similar HRQoL. In the recently published AVM research, the most commonly used cut points for mRS dichotomization were between mRS 1 and 2 and between mRS 2 and 3. Conclusions Using 15D, we were able to find significant differences in the HRQoL between mRS 0 and mRS 1 AVM patients, against the recent findings on stroke patients using EQ-5D in their analyses. Although the dichotomization cut point is commonly set between mRS 1 and 2, patients in these grades had a similar HRQoL and a decreased ability to continue their premorbid lifestyle, in contrast to patients in mRS 0.
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Affiliation(s)
- Anni Pohjola
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland.
| | - Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
| | - Risto P Roine
- Group Administration, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Harri P Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
| | - Hanna Lehto
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5B, 00260, Helsinki, Finland
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16
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Serna Candel C, Aguilar Pérez M, Bäzner H, Henkes H, Hellstern V. First-Pass Reperfusion by Mechanical Thrombectomy in Acute M1 Occlusion: The Size of Retriever Matters. Front Neurol 2021; 12:679402. [PMID: 34267722 PMCID: PMC8276778 DOI: 10.3389/fneur.2021.679402] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction: Single-pass complete reperfusion using stent retrievers has been shown to improve functional outcome in patients with large vessel occlusion strokes. The aim of this study was to investigate the optimal size of stent retrievers to achieve one-pass complete reperfusion by mechanical thrombectomy. Methods: The study evaluated the results of aspiration-assisted mechanical thrombectomy of acute isolated occlusion of the middle cerebral artery in the M1 segment with a novel 5 × 40-mm stent retriever compared to the usual 4 × 20-mm device. Reperfusion status was quantified using the Thrombolysis In Cerebral Infarction (TICI) scale. We hypothesized that thrombectomy of M1 occlusions with 5 × 40-mm stent retriever yields higher rates of complete first-pass reperfusion (FP) (TICI ≥2c after one pass) and successful or modified FP (mFP) (TICI ≥2b after one pass) than thrombectomy with 4 × 20. We included isolated M1 occlusions treated with pRESET 5 × 40 (phenox) as first-choice device for thrombectomy and compared with M1 occlusions treated with pRESET 4 × 20. We excluded patients with additional occlusions or tandem stenosis or who received an intracranial stent or angioplasty as a part of the endovascular treatment. Results: One hundred thirteen patients were included in the 4 × 20 group and 57 patients in the 5 × 40 group. The 5 × 40 group achieved higher FP compared to 4 × 20 group [61.4% (35 of 57 patients) vs. 40.7% (46 of 113), respectively; adjusted odds ratio (OR) and 95% confidence interval (95% CI) = 2.20 (1.08-4.48), p = 0.030] and a higher mFP [68.4%, 39 of 57 patients vs. 48.7%, 55 of 113; adjusted OR (95% CI) = 2.11 (1.04-4.28), p = 0.037]. Frequency of successful reperfusion (TICI ≥2b) was similar in both groups (100 vs. 97.3%), but frequency of complete reperfusion (TICI ≥2c) was higher in the 5 × 40 group [82.5 vs. 61.9%, adjusted OR (95% CI) = 2.47 (1.01-6.04), p = 0.047]. Number of passes to achieve reperfusion was lower in the 5 × 40 group than in the 4 × 20 group [1.6 ± 1.1 vs. 2 ± 1.4, p = 0.033; adjusted incidence rate ratio (95% CI) = 0.84 (0.69-1.03), p = 0.096]. Modified Rankin scale at 90 days was similar in 5 × 40 and 4 × 20 groups. Conclusions: The size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieves a higher complete and successful FP and higher successful reperfusion compared to a shorter stent retriever.
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Affiliation(s)
| | | | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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Yogendrakumar V, Ramsay T, Menon BK, Qureshi AI, Saver JL, Dowlatshahi D. Hematoma Expansion Shift Analysis to Assess Acute Intracerebral Hemorrhage Treatments. Neurology 2021; 97:e755-e764. [PMID: 34144995 DOI: 10.1212/wnl.0000000000012393] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/21/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Hematoma expansion (HE) is commonly analyzed as a dichotomous outcome in intracerebral hemorrhage (ICH) trials. In this proof-of-concept study, we propose an HE shift analysis model as a method to improve the evaluation of candidate ICH therapies. METHODS Using data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, we performed HE shift analysis in response to intensive blood pressure lowering by generating polychotomous strata based on previously established HE definitions, percentile/absolute quartiles of hematoma volume change, and quartiles of 24-hour follow-up hematoma volumes. The relationship between blood pressure treatment and HE shift was explored with proportional odds models. RESULTS The primary analysis population included 863 patients. In both treatment groups, approximately one-third of patients exhibited no HE. With the use of a trichotomous HE stratification, the highest strata of ≥33% revealed a 5.8% reduction in hematoma growth for those randomized to intensive therapy (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.60-0.99). Using percentile quartiles of hematoma volume change, we observed a favorable shift to reduce growth in patients treated with intensive therapy (aOR 0.73, 95% CI 0.57-0.93). Similarly, in a tetrachotomous analysis of 24-hour follow-up hematoma volumes, shifts in the highest stratum (>21.9 mL) were most notable. CONCLUSIONS Our findings suggest that intensive blood pressure reduction may preferentially mitigate growth in patients at risk of high volume HE. A shift analysis model of HE provides additional insights into the biological effects of a given therapy and may be an additional way to assess hemostatic agents in future studies. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier:NCT01176565.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles
| | - Tim Ramsay
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles
| | - Bijoy K Menon
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles
| | - Adnan I Qureshi
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles
| | - Jeffrey L Saver
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles
| | - Dar Dowlatshahi
- From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine, Neurology (V.Y., D.D.), and School of Epidemiology and Public Health (T.R., D.D.), University of Ottawa and Ottawa Hospital Research Institute (T.R., D.D.), Ontario; Department of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), Cumming School of Medicine and the Hotchkiss Brain Institute (B.K.M.), University of Calgary, Alberta, Canada; Zeenat Qureshi Stroke Institute (A.L.Q.), University of Missouri, Columbia; and David Geffen School of Medicine Comprehensive Stroke Center (J.L.S.), University of California Los Angeles.
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18
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Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion. Rev Neurol (Paris) 2021; 177:955-963. [PMID: 33487410 DOI: 10.1016/j.neurol.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/06/2020] [Accepted: 09/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) and mild neurological deficit is uncertain. AIMS To investigate efficacy and safety of MT in patients with acute AIS-LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications. METHODS We included consecutive patients with acute AIS-LVO and National Institute of Stroke Scale (NIHSS) score<8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0-1 and 0-2 (or similar to pre-stroke). RESULTS We included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P<0.001 and favourable outcome 82.9% versus 31.6%, P<0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH. CONCLUSIONS Achieving successful recanalisation appears beneficial and safe in acute AIS-LVO patients with NIHSS<8 before MT.
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Ceyisakar IE, van Leeuwen N, Dippel DWJ, Steyerberg EW, Lingsma HF. Ordinal outcome analysis improves the detection of between-hospital differences in outcome. BMC Med Res Methodol 2021; 21:4. [PMID: 33407167 PMCID: PMC7788719 DOI: 10.1186/s12874-020-01185-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/02/2020] [Indexed: 11/22/2022] Open
Abstract
Background There is a growing interest in assessment of the quality of hospital care, based on outcome measures. Many quality of care comparisons rely on binary outcomes, for example mortality rates. Due to low numbers, the observed differences in outcome are partly subject to chance. We aimed to quantify the gain in efficiency by ordinal instead of binary outcome analyses for hospital comparisons. We analyzed patients with traumatic brain injury (TBI) and stroke as examples. Methods We sampled patients from two trials. We simulated ordinal and dichotomous outcomes based on the modified Rankin Scale (stroke) and Glasgow Outcome Scale (TBI) in scenarios with and without true differences between hospitals in outcome. The potential efficiency gain of ordinal outcomes, analyzed with ordinal logistic regression, compared to dichotomous outcomes, analyzed with binary logistic regression was expressed as the possible reduction in sample size while keeping the same statistical power to detect outliers. Results In the IMPACT study (9578 patients in 265 hospitals, mean number of patients per hospital = 36), the analysis of the ordinal scale rather than the dichotomized scale (‘unfavorable outcome’), allowed for up to 32% less patients in the analysis without a loss of power. In the PRACTISE trial (1657 patients in 12 hospitals, mean number of patients per hospital = 138), ordinal analysis allowed for 13% less patients. Compared to mortality, ordinal outcome analyses allowed for up to 37 to 63% less patients. Conclusions Ordinal analyses provide the statistical power of substantially larger studies which have been analyzed with dichotomization of endpoints. We advise to exploit ordinal outcome measures for hospital comparisons, in order to increase efficiency in quality of care measurements. Trial registration We do not report the results of a health care intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-020-01185-7.
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Affiliation(s)
- I E Ceyisakar
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - N van Leeuwen
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Stroke Center, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - H F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
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20
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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21
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Dodd LE, Follmann D, Wang J, Koenig F, Korn LL, Schoergenhofer C, Proschan M, Hunsberger S, Bonnett T, Makowski M, Belhadi D, Wang Y, Cao B, Mentre F, Jaki T. Endpoints for randomized controlled clinical trials for COVID-19 treatments. Clin Trials 2020; 17:472-482. [PMID: 32674594 PMCID: PMC7611901 DOI: 10.1177/1740774520939938] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Endpoint choice for randomized controlled trials of treatments for novel coronavirus-induced disease (COVID-19) is complex. Trials must start rapidly to identify treatments that can be used as part of the outbreak response, in the midst of considerable uncertainty and limited information. COVID-19 presentation is heterogeneous, ranging from mild disease that improves within days to critical disease that can last weeks to over a month and can end in death. While improvement in mortality would provide unquestionable evidence about the clinical significance of a treatment, sample sizes for a study evaluating mortality are large and may be impractical, particularly given a multitude of putative therapies to evaluate. Furthermore, patient states in between "cure" and "death" represent meaningful distinctions. Clinical severity scores have been proposed as an alternative. However, the appropriate summary measure for severity scores has been the subject of debate, particularly given the variable time course of COVID-19. Outcomes measured at fixed time points, such as a comparison of severity scores between treatment and control at day 14, may risk missing the time of clinical benefit. An endpoint such as time to improvement (or recovery) avoids the timing problem. However, some have argued that power losses will result from reducing the ordinal scale to a binary state of "recovered" versus "not recovered." METHODS We evaluate statistical power for possible trial endpoints for COVID-19 treatment trials using simulation models and data from two recent COVID-19 treatment trials. RESULTS Power for fixed time-point methods depends heavily on the time selected for evaluation. Time-to-event approaches have reasonable statistical power, even when compared with a fixed time-point method evaluated at the optimal time. DISCUSSION Time-to-event analysis methods have advantages in the COVID-19 setting, unless the optimal time for evaluating treatment effect is known in advance. Even when the optimal time is known, a time-to-event approach may increase power for interim analyses.
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Affiliation(s)
- Lori E Dodd
- Biostatistics Research Branch, National Institute Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Dean Follmann
- Biostatistics Research Branch, National Institute Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Franz Koenig
- Center for Medical Statistics, Informatics and Intelligent Systems; Medical University of Vienna, Vienna, Austria
| | - Lisa L Korn
- Department of Medicine (Rheumatology, Allergy, and Immunology Section) and Department of Immunobiology, Yale University, New Haven, CT, USA
| | | | - Michael Proschan
- Biostatistics Research Branch, National Institute Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Sally Hunsberger
- Biostatistics Research Branch, National Institute Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - Drifa Belhadi
- Université de Paris, IAME, Inserm, Paris, France
- AP-HP, Hôpital Bichat, DEBRC, Paris, France
| | - Yeming Wang
- Center of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Beijing, China
- China-Japan Friendship Hospital, Department of Respiratory Medicine, Capital Medical University, Beijing, China
| | - Bin Cao
- Center of Respiratory Medicine, Department of Pulmonary and Critical Care Medicine, National Clinical Research Center for Respiratory Diseases, Beijing, China
- China-Japan Friendship Hospital, Department of Respiratory Medicine, Capital Medical University, Beijing, China
| | - France Mentre
- Université de Paris, IAME, Inserm, Paris, France
- AP-HP, Hôpital Bichat, DEBRC, Paris, France
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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22
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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23
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Petersen NH, Silverman A, Strander SM, Kodali S, Wang A, Sansing LH, Schindler JL, Falcone GJ, Gilmore EJ, Jasne AS, Cord B, Hebert RM, Johnson M, Matouk CC, Sheth KN. Fixed Compared With Autoregulation-Oriented Blood Pressure Thresholds After Mechanical Thrombectomy for Ischemic Stroke. Stroke 2020; 51:914-921. [PMID: 32078493 DOI: 10.1161/strokeaha.119.026596] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Loss of cerebral autoregulation in the acute phase of ischemic stroke leaves patients vulnerable to blood pressure (BP) changes. Effective BP management after endovascular thrombectomy may protect the brain from hypoperfusion or hyperperfusion. In this observational study, we compared personalized, autoregulation-based BP targets to static systolic BP thresholds. Methods- We prospectively enrolled 90 patients undergoing endovascular thrombectomy for stroke. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy-derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in mean arterial pressure. The resulting autoregulatory index was used to trend the BP range at which autoregulation was most preserved. Percent time that mean arterial pressure exceeded the upper limit of autoregulation or decreased below the lower limit of autoregulation was calculated for each patient. Time above fixed systolic BP thresholds was computed in a similar fashion. Functional outcome was measured with the modified Rankin Scale at 90 days. Results- Personalized limits of autoregulation were successfully computed in all 90 patients (age 71.6±16.2, 47% female, mean National Institutes of Health Stroke Scale 13.9±5.7, monitoring time 28.0±18.4 hours). Percent time with mean arterial pressure above the upper limit of autoregulation associated with worse 90-day outcomes (odds ratio per 10% 1.84 [95% CI, 1.3-2.7] P=0.002), and patients with hemorrhagic transformation spent more time above the upper limit of autoregulation (10.9% versus 16.0%, P=0.042). Although there appeared to be a nonsignificant trend towards worse outcome with increasing time above systolic BP thresholds of 140 mm Hg and 160 mm Hg, the effect sizes were smaller compared with the personalized approach. Conclusions- Noninvasive determination of personalized BP thresholds for stroke patients is feasible. Deviation from these limits may increase risk of further brain injury and poor functional outcome. This approach may present a better strategy compared with the classical approach of maintaining systolic BP below a predetermined value, though a randomized trial is needed to determine the optimal approach for hemodynamic management.
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Affiliation(s)
- Nils H Petersen
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Andrew Silverman
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Sumita M Strander
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Sreeja Kodali
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Anson Wang
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Lauren H Sansing
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Joseph L Schindler
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Guido J Falcone
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Emily J Gilmore
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Adam S Jasne
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
| | - Branden Cord
- Department of Neurosurgery (B.C., R.M.H., C.C.M.), Yale University School of Medicine, New Haven, CT
| | - Ryan M Hebert
- Department of Neurosurgery (B.C., R.M.H., C.C.M.), Yale University School of Medicine, New Haven, CT
| | - Michele Johnson
- Department of Radiology (M.J.), Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery (B.C., R.M.H., C.C.M.), Yale University School of Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Department of Neurology (N.H.P., A.S., S.M.S., S.K., A.W., L.H.S., J.L.S., G.J.F., E.J.G., A.S.J., K.N.S.), Yale University School of Medicine, New Haven, CT
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24
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Boers AMM, Jansen IGH, Brown S, Lingsma HF, Beenen LFM, Devlin TG, Román LS, Heo JH, Ribó M, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, Donnan GA, Mas JL, Oppenheim C, Dowling RJ, Moulin T, Agrinier N, Lopes DK, Aja Rodríguez L, Compagne KCJ, Al-Ajlan FS, Madigan J, Albers GW, Soize S, Blasco J, Davis SM, Nogueira RG, Dávalos A, Menon BK, van der Lugt A, Muir KW, Roos YBWEM, White P, Mitchell PJ, Demchuk AM, van Zwam WH, Jovin TG, van Oostenbrugge RJ, Dippel DWJ, Campbell BCV, Guillemin F, Bracard S, Hill MD, Goyal M, Marquering HA, Majoie CBLM. Mediation of the Relationship Between Endovascular Therapy and Functional Outcome by Follow-up Infarct Volume in Patients With Acute Ischemic Stroke. JAMA Neurol 2019; 76:194-202. [PMID: 30615038 DOI: 10.1001/jamaneurol.2018.3661] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. Objective To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. Design, Setting, and Participants Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. Main Outcome and Measure The 90-day functional outcome via the modified Rankin Scale (mRS). Results Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. Conclusions and Relevance In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
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Affiliation(s)
- Anna M M Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands
| | - Ivo G H Jansen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Scott Brown
- Altair Biostatistics, Mooresville, North Carolina
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Thomas G Devlin
- Department of Neurology, Erlanger Hospital, University of Tennessee at Chattanooga
| | - Luis San Román
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University, Seoul, South Korea
| | - Marc Ribó
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
| | - Mohammed A Almekhlafi
- Department of Neurology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Jeanne Teitelbaum
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Patricia Cuadras
- Department of Radiology, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | | | - Marine Beaumont
- Inserm CIC-IT 1433, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Martin M Brown
- Institute of Neurology, University College London, London, United Kingdom
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Dallas
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Jean Louis Mas
- Department of Neurology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Richard J Dowling
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Thierry Moulin
- Department of Neurology, University Hospital of Besançon, University of Franche-Comté, Besançon, France
| | - Nelly Agrinier
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Demetrius K Lopes
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Lucía Aja Rodríguez
- Neuroradiology Department, Hospital Universitari de Bellvitge, Barcelona, Catalonia, Spain
| | - Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Gregory W Albers
- Department of Neurology, Stanford Stroke Center, Palo Alto, California
| | - Sebastien Soize
- Department of Neuroradiology, University Hospital of Reims, Reims, France
| | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Raul G Nogueira
- Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tudor G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Francis Guillemin
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U947, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
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25
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Serna Candel C, Aguilar Pérez M, Hellstern V, AlMatter M, Bäzner H, Henkes H. Recanalization of Emergent Large Intracranial Vessel Occlusion through Intravenous Thrombolysis: Frequency, Clinical Outcome, and Reperfusion Pattern. Cerebrovasc Dis 2019; 48:115-123. [PMID: 31747667 DOI: 10.1159/000503850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/02/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND According to a recent meta-analysis, 1 out of 10 patients with emergent large intracranial vessel occlusion (ELVO) causing stroke have recanalization after intravenous thrombolysis (IVT) alone. However, rate, clinical outcome, and recanalization pattern of this phenomenon are poorly understood. OBJECTIVES AND METHODS Patients with ELVO recanalized only by IVT were analyzed, and frequency of recanalization, clinical outcome, safety variables, and reperfusion pattern were assessed. These patients were compared to a group of patients with ELVO who underwent endovascular thrombectomy with or without prior IVT. RESULTS Successful or sufficient recanalization after IVT alone occurred in 81 of 760 patients (10.6%) with ELVO who had been referred for endovascular thrombectomy. These 81 patients (group 1) were compared to a group of patients receiving endovascular thrombectomy with prior IVT (group 2) or without (group 3). A good clinical outcome at 90 days was seen in 61.7% of patients in group 1, 32.2% in group 2, and 34.5% in group 3 (p < 0.001). The 3 groups had no significant differences in intracranial hemorrhage. IVT was not independently associated with symptomatic intracranial hemorrhage, parenchymal hematoma, or subarachnoid hemorrhage. Mortality at 90 days was 9.9% in group 1, 20.7% in group 2, and 29.6% in group 3 (p < 0.001). After adjusting for all relevant variables, outcome and mortality differences were nonsignificant. No difference in the rate of successful reperfusion (modified treatment in cerebral ischemia [mTICI] 2b/3) was found. A reperfusion mTICI 3 was achieved in 18.5% in group 1, 60.7% in group 2, and 57.1% in group 3 (p < 0.001). Patients in group 1 had lower chance of achieving a complete recanalization (mTICI 3) compared to patients in group 2, OR 0.15 (95% CI 0.08-0.29) and in group 3, OR 0.17 (95% CI 0.09-0.32; p < 0.001). CONCLUSIONS Primary IVT in ELVO caused a recanalization rate of 10.6%, making endovascular treatment either unnecessary or impossible. Early recanalization of ELVO with only IVT is associated with a 61.7% independence rate at 90 days and similar successful reperfusion rates (mTICI2b/3) compared to ELVO treated with endovascular treatment, with or without previous IVT. However, recanalization only through IVT achieves a lower rate of mTICI 3 reperfusion when compared to endovascular treatment.
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Affiliation(s)
- Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany,
| | - Marta Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
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Silverman A, Kodali S, Strander S, Gilmore EJ, Kimmel A, Wang A, Cord B, Falcone G, Hebert R, Matouk C, Sheth KN, Petersen NH. Deviation From Personalized Blood Pressure Targets Is Associated With Worse Outcome After Subarachnoid Hemorrhage. Stroke 2019; 50:2729-2737. [PMID: 31495332 PMCID: PMC6756936 DOI: 10.1161/strokeaha.119.026282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Optimal blood pressure (BP) management during the early stages of aneurysmal subarachnoid hemorrhage remains uncertain. Observational studies have found worse outcomes in patients with increased hemodynamic variability, suggesting BP optimization as a potential neuroprotective strategy. In this study, we calculated personalized BP targets at which cerebral autoregulation was best preserved. We analyzed how deviation from these limits correlates with functional outcome. Methods- We prospectively enrolled 31 patients with aneurysmal subarachnoid hemorrhage. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation-a surrogate for cerebral blood flow-as well as intracranial pressure (ICP) in response to changes in mean arterial pressure using time-correlation analysis. The resulting autoregulatory indices were used to identify the upper and lower limit of autoregulation. Percent time that mean arterial pressure exceeded limits of autoregulation was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using ordinal multivariate logistic regression. Results- Personalized limits of autoregulation were computed in all patients (age 57.5±13.4, 23F, mean World Federation of Neurological Surgeons 2±1, monitoring time 67.8±50.8 hours). Optimal BP and limits of autoregulation were calculated on average for 89.5±6.7% of the total monitoring period. ICP- and NIRS-derived optimal pressures strongly correlated with one another (P<0.0001). Percent time that mean arterial pressure deviated from limits of autoregulation significantly associated with worse functional outcome at discharge (NIRS, P=0.001; ICP, P=0.004) and 90 days (NIRS, P=0.002; ICP, P=0.003), adjusting separately for age, World Federation of Neurological Surgeons, vasospasm, and delayed cerebral ischemia. Conclusions- Both invasive (ICP) and noninvasive (NIRS) determination of personalized BP targets after aneurysmal subarachnoid hemorrhage is feasible, and these 2 approaches revealed significant collinearity. Furthermore, exceeding individualized limits of autoregulation was associated with poor functional outcomes.
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Affiliation(s)
| | - Sreeja Kodali
- Department of Neurology, Yale Medical School, New Haven, CT
| | | | | | | | - Anson Wang
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Branden Cord
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Guido Falcone
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Charles Matouk
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology, Yale Medical School, New Haven, CT
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27
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Yuan T, Ren G, Hu X, Geng L, Li X, Xia S, Quan G. Added assessment of middle cerebral artery and atrial fibrillation to FLAIR vascular hyperintensity-DWI mismatch would improve the outcome prediction of acute infarction in patients with acute internal carotid artery occlusion. Neurol Sci 2019; 40:2617-2624. [PMID: 31392639 DOI: 10.1007/s10072-019-04029-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/22/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Whether fluid-attenuated inversion recovery (FLAIR) vascular hyperintensities (FVH)-DWI mismatch could predict the outcome or not remains in debate. The aim of this study was to identify if FVH combined with the other markers improved favorable outcome prediction of acute infarctions in patients with unilateral acute internal carotid artery (ICA) occlusion. METHODS Consecutive 68 adult acute middle cerebral artery (MCA) territory infarction patients caused by acute ICA occlusion, including favorable (n = 38, mRS ≤ 2) and unfavorable (n = 30, mRS > 2) groups, were enrolled in this retrospective analysis. The diagnostic efficiency of favorable clinical outcome of FVH-DWI mismatch was compared with those of DWI lesions volumetry and the combined marker of FVH-DWI mismatch and other factors. RESULTS There were more prominent FVH-DWI mismatch (≥ 3 sections) (84%), less atrial fibrillation (AFib) (13%), and more tandem MCA normal or mild stenosis (63%) in favorable outcome group than those (30%, 40%, and 27%, respectively) in unfavorable group. Univariate and multivariate analyses showed that the prominent FVH-DWI mismatch was the positive predictive factor for favorable outcome (OR = 2.643 and 3.200). Prominent FVH-DWI mismatch, in combination with tandem MCA normal or mild stenosis, and absence of Afib, had better performance (AUC = 0.875) than that of initial DWI lesion volumetry (AUC = 0.854) and any other single factor (AUC = 0.634~0.820) in predicting favorable outcome. CONCLUSIONS Prominent FVH-DWI mismatch was associated with favorable outcome in acute infarctions in unilateral ICA occlusion patients. Its predictive performance would be improved when combined with the assessment of tandem lesions of MCA and AFib.
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Affiliation(s)
- Tao Yuan
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guoli Ren
- Department of Medical Imaging, Liaocheng People's Hospital, Liaocheng, China
| | - Xianning Hu
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lina Geng
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xueqing Li
- Department of Medical Imaging, Lingshou County People's Hospital, Shijiazhuang, China
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Guanmin Quan
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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28
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Landman T, Schoon Y, Warlé M, De Leeuw FE, Thijssen D. The effect of repeated remote ischemic postconditioning on infarct size in patients with an ischemic stroke (REPOST): study protocol for a randomized clinical trial. Trials 2019; 20:167. [PMID: 30876432 PMCID: PMC6419836 DOI: 10.1186/s13063-019-3264-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 02/27/2019] [Indexed: 01/28/2023] Open
Abstract
Background Remote ischemic postconditioning (rIPostC) refers to the observation that repeated, short periods of ischemia protect remote areas against tissue damage during and after prolonged ischemia. Based on previous observations of a potential neuroprotective effect of rIPostC, the aim of this study is to evaluate whether repeated rIPostC after an ischemic stroke can reduce infarct size, which could be translated to an improvement in clinical outcomes. Methods/design We will enroll 200 ischemic stroke patients to daily rIPostC or sham conditioning during hospitalization into a randomized single-blind placebo-controlled trial. The intervention consists of twice daily exposure to four cycles of 5-min cuff inflation around the upper arm to > 20 mmHg above systolic blood pressure (i.e., rIPostC) or 50 mmHg (i.e., control), followed by 5 minutes of deflation. The primary outcome is infarct size, measured using an MRI diffusion-weighted image at the end of hospitalization. Secondary outcomes include the Modified Rankin Scale, National Institutes of Health Stroke Scale, quality of life, and cardiovascular and cerebrovascular morbidity and mortality. To explore possible underlying mechanisms of rIPostC, venous blood will be sampled to assess biomarkers of inflammation and vascular health. Discussion Previous studies in animals and humans, using a single bout of remote ischemic conditioning, report a potential effect of rIPostC in attenuating neural damage. Although repeated rIPostC has been investigated for cardiovascular disease patients and preclinical stroke models, no previous study has explored the potential physiological and clinical effects of repeatedly applying rIPostC during the hospitalization phase after a stroke. Trial registration Netherlands Trial Register, NTR6880. Registered on 8 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3264-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thijs Landman
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Michiel Warlé
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Frank-Erik De Leeuw
- Centre for Cognitive Neuroscience, Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Dick Thijssen
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
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29
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van Leeuwen N, Walgaard C, van Doorn PA, Jacobs BC, Steyerberg EW, Lingsma HF. Efficient design and analysis of randomized controlled trials in rare neurological diseases: An example in Guillain-Barré syndrome. PLoS One 2019; 14:e0211404. [PMID: 30785890 PMCID: PMC6382155 DOI: 10.1371/journal.pone.0211404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/14/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) pose specific challenges in rare and heterogeneous neurological diseases due to the small numbers of patients and heterogeneity in disease course. Two analytical approaches have been proposed to optimally handle these issues in RCTs: covariate adjustment and ordinal analysis. We investigated the potential gain in efficiency of these approaches in rare and heterogeneous neurological diseases, using Guillain-Barré syndrome (GBS) as an example. METHODS We analyzed two published GBS trials with primary outcome 'at least one grade improvement' on the GBS disability scale. We estimated the treatment effect using logistic regression models with and without adjustment for prognostic factors. The difference between the unadjusted and adjusted estimates was disentangled in imbalance (random differences in baseline covariates between treatment arms) and stratification (change of the estimate due to covariate adjustment). Second, we applied proportional odds regression, which exploits the ordinal nature of the GBS disability score. The standard error of the estimated treatment effect indicated the statistical efficiency. RESULTS Both trials were slightly imbalanced with respect to baseline characteristics, which was corrected in the adjusted analysis. Covariate adjustment increased the estimated treatment effect in the two trials by 8% and 18% respectively. Proportional odds analysis resulted in lower standard errors indicating more statistical power. CONCLUSION Covariate adjustment and proportional odds analysis most efficiently use the available data and ensure balance between the treatment arms to obtain reliable and valid treatment effect estimates. These approaches merit application in future trials in rare and heterogeneous neurological diseases like GBS.
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Affiliation(s)
- Nikki van Leeuwen
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Christa Walgaard
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter A. van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bart C. Jacobs
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hester F. Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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30
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Compagne KCJ, Goldhoorn RB, Uyttenboogaart M, van Oostenbrugge RJ, van Zwam WH, van Doormaal PJ, Dippel DWJ, van der Lugt A, Emmer BJ, van Es ACGM. Acute Endovascular Treatment of Patients With Ischemic Stroke From Intracranial Large Vessel Occlusion and Extracranial Carotid Dissection. Front Neurol 2019; 10:102. [PMID: 30837934 PMCID: PMC6390807 DOI: 10.3389/fneur.2019.00102] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction: Carotid artery dissection (CAD) and atherosclerotic carotid artery occlusion (ACAO) are major causes of a tandem occlusion in patients with intracranial large vessel occlusion (LVO). Presence of tandem occlusions may hamper intracranial access and potentially increases the risk of procedural complications of endovascular treatment (EVT). Our aim was to assess neurological, functional and technical outcome and complications of EVT for intracranial LVO in patients with CAD in comparison to patients with ACAO and to patients without CAD or ACAO. Methods: We analyzed data of the MR CLEAN trial intervention arm and MR CLEAN Registry, acquired in 16 Dutch EVT-centers. Primary outcome was the change in stroke severity by comparing the National Institute of Health Stroke Scale (NIHSS) score at 24–48 h after treatment vs. baseline. Secondary outcomes included reperfusion rate and symptomatic intracranial hemorrhage (sICH). We compared outcomes and complications between patients with CAD vs. patients with ACAO and patients without CAD or ACAO. Results: In total, we identified 74 (4.7%) patients with CAD, 92 (5.9%) patients with ACAO and 1398 (89.4%) patients without CAD or ACAO. Neurological improvement at short-term after EVT in patients with CAD was significantly better compared to ACAO (resp. mean −5 vs. mean −1 NIHSS point; p = 0.03) and did not differ compared to patients without CAD or ACAO (−4 NIHSS points; p = 0.62). Rates of successful reperfusion in patients with CAD (47%) was comparable to patients with ACAO (47%; p = 1.00), but was less often achieved compared to patients without CAD or ACAO (58%; p = 0.08). Occurrence of sICH did not differ significantly between CAD patients (5%) and ACAO (11%; p = 0.33) or without CAD/ACAO (6%; p = 1.00). Conclusion: EVT in patients with intracranial LVO due to CAD results in neurological improvement comparable to patients without tandem occlusions. Therefore, carotid artery dissection by itself should not be a contraindication for endovascular treatment in stroke patients with intracranial large vessel occlusion. Although more challenging endovascular procedures are to be suspected in both patients with CAD or ACAO, accurate distinction between CAD and ACAO might influence clinical decision making as better clinical outcome can be expected in patients with CAD.
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Affiliation(s)
- Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands.,Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - R B Goldhoorn
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Wim H van Zwam
- Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.,Department of Radiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Pieter J van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Bart J Emmer
- Department of Radiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
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31
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Compagne KCJ, van der Sluijs PM, van den Wijngaard IR, Roozenbeek B, Mulder MJHL, van Zwam WH, Emmer BJ, Majoie CBLM, Yoo AJ, Lycklama À Nijeholt GJ, Lingsma HF, Dippel DWJ, van der Lugt A, van Es ACGM. Endovascular Treatment: The Role of Dominant Caliber M2 Segment Occlusion in Ischemic Stroke. Stroke 2019; 50:419-427. [PMID: 31287757 PMCID: PMC6358188 DOI: 10.1161/strokeaha.118.023117] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- It is unclear whether endovascular treatment (EVT) is beneficial for patients with acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery. We aimed to compare functional outcomes, technical aspects, and complications of EVT between patients with acute ischemic stroke because of M2 and M1 occlusions in clinical practice. Furthermore, outcome and complications after EVT in dominant and nondominant caliber M2 division occlusions were studied. Methods- Data were obtained from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) which is an ongoing observational study in 16 Dutch centers performing EVT in the Netherlands. Functional outcome was measured with the modified Rankin Scale score at 90 days. Neurological recovery (delta National Institutes of Health Stroke Scale), successful reperfusion rates (extended Thrombolysis in Cerebral Infarction ≥2B), and safety outcomes were also investigated. Associations between occlusion location and outcome were analyzed with ordinal logistic regression models, with adjustment for other prognostic factors. Results- In total, 244 (24%) patients with an M2 and 759 (76%) patients with an M1 occlusion who underwent EVT were analyzed. Functional outcomes were not significantly different between patients with M2 versus M1 occlusions (adjusted common odds ratio, 1.24; 95% CI, 0.87-1.73). Occurrence of symptomatic intracerebral hemorrhage was also similar for M2 and M1 occlusions (6.6% versus 5.9%; P=0.84). Further analysis about dominance of an M2 branch was performed in 175 (72%) patients. Neurological recovery was comparable (mean delta National Institutes of Health Stroke Scale, -2±10 for dominant M2, -5±5 for nondominant M2, and -4±9 [ P=0.24] for M1 occlusions). Furthermore, the effect of reperfusion status on functional outcome was comparable between occlusion divisions (common odds ratio, 1.27; 95% CI, 1.06-1.53 for dominant M2; common odds ratio, 1.32; 95% CI, 0.93-1.87 for nondominant M2; and common odds ratio, 1.35; 95% CI, 1.24-1.46 for M1 occlusions). Conclusions- Outcomes and complication rates after EVT were similar in patients with M2 and M1 occlusions. Although based on observational data and a limited sample size, a similar association of reperfusion status with functional outcome for all subgroups provides no evidence that patients with either a dominant or a nondominant M2 occlusion should be routinely excluded from EVT.
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Affiliation(s)
- Kars C J Compagne
- From the Department of Radiology and Nuclear Medicine (K.C.J.C., P.M.v.d.S., A.v.d.L., A.C.G.M.v.E.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (K.C.J.C., B.R., M.J.H.L.M., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Pieter M van der Sluijs
- From the Department of Radiology and Nuclear Medicine (K.C.J.C., P.M.v.d.S., A.v.d.L., A.C.G.M.v.E.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology (I.R.v.d.W.), Haaglanden Medical Center (HMC), The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, the Netherlands (I.R.v.d.W.)
| | - Bob Roozenbeek
- Department of Neurology (K.C.J.C., B.R., M.J.H.L.M., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Maxim J H L Mulder
- Department of Neurology (K.C.J.C., B.R., M.J.H.L.M., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, the Netherlands (W.H.v.Z.).,Cardiovascular Research Institute Maastricht, the Netherlands (W.H.v.Z.)
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands (B.J.E., C.B.L.M.M.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands (B.J.E., C.B.L.M.M.)
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | | | - Hester F Lingsma
- Department of Public Health (H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (K.C.J.C., B.R., M.J.H.L.M., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- From the Department of Radiology and Nuclear Medicine (K.C.J.C., P.M.v.d.S., A.v.d.L., A.C.G.M.v.E.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- From the Department of Radiology and Nuclear Medicine (K.C.J.C., P.M.v.d.S., A.v.d.L., A.C.G.M.v.E.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Lindekleiv H, Berge E, Bruins Slot KMH, Wardlaw JM. Percutaneous vascular interventions versus intravenous thrombolytic treatment for acute ischaemic stroke. Cochrane Database Syst Rev 2018; 10:CD009292. [PMID: 30365156 PMCID: PMC6516947 DOI: 10.1002/14651858.cd009292.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Most ischaemic strokes are caused by blockage of a cerebral artery by a thrombus. Intravenous administration of recombinant tissue plasminogen activator given within 4.5 hours is now standard treatment for this condition. Percutaneous vascular interventions use an intra-arterial, mechanical approach for thrombus disruption or removal (thrombectomy). Recent randomised trials indicate that percutaneous vascular interventions are superior to usual care (usual care usually included intravenous thrombolysis). However, intravenous thrombolysis was usually given in both arms of the trial and there was a lack of direct comparison of percutaneous vascular interventions with intravenous thrombolysis. OBJECTIVES To assess the effectiveness and safety of percutaneous vascular interventions compared with intravenous thrombolytic treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last search: August 2018). In addition, in September 2017, we searched the following electronic databases: CENTRAL, MEDLINE, Embase, and Science Citation Index; and Stroke Trials Registry, and US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) that directly compared a percutaneous vascular intervention with intravenous thrombolytic treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data, and assessed risk of bias. We obtained both published and unpublished data. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included four trials with 450 participants. Data on functional outcome and death at end of follow-up were available for 443 participants from three trials. Compared with intravenous thrombolytic therapy, percutaneous vascular intervention did not improve the proportion of participants with good functional outcome (modified Rankin Scale score 0 to 2, risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.25, P = 0.92). The quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). At the end of follow-up, there was a non-significant increase in the proportion of participants who died in the percutaneous vascular intervention group (RR 1.34, 95% CI 0.84 to 2.14, P = 0.21). The quality of evidence was low (wide confidence interval). There was no difference in the proportion of participants with symptomatic intracranial haemorrhages between the intervention and control groups (RR 0.99, 95% CI 0.50 to 1.95, P = 0.97). The quality of evidence was low (wide confidence interval). Data on vascular status (recanalisation rate) were only available for seven participants from one trial; we considered this inadequate for statistical analyses. AUTHORS' CONCLUSIONS The present review directly compared intravenous thrombolytic treatment with percutaneous vascular interventions for ischaemic stroke. We found no evidence from RCTs that percutaneous vascular interventions are superior to intravenous thrombolytic treatment with respect to functional outcome. Quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). New trials with adequate sample sizes are warranted because of the rapid development of new techniques and devices for such interventions.
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Affiliation(s)
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | | | - Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
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Ganesh A, Luengo-Fernandez R, Wharton RM, Rothwell PM. Ordinal vs dichotomous analyses of modified Rankin Scale, 5-year outcome, and cost of stroke. Neurology 2018; 91:e1951-e1960. [PMID: 30341155 PMCID: PMC6260198 DOI: 10.1212/wnl.0000000000006554] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/08/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To compare how 3 common representations (ordinal vs dichotomized as 0–1/2–6 or 0–2/3–6) of the modified Rankin Scale (mRS)—a commonly used trial outcome measure—relate to long-term outcomes, and quantify trial ineligibility rates based on premorbid mRS. Methods In consecutive patients with ischemic stroke in a population-based, prospective, cohort study (Oxford Vascular Study; 2002–2014), we related 3-month mRS to 1-year and 5-year disability and death (logistic regressions), and health/social care costs (generalized linear model), adjusted for age/sex, and compared goodness-of-fit values (C statistic, mean absolute error). We also calculated the proportion of patients in whom premorbid mRS score >1 or >2 would result in exclusion from trials using dichotomous analysis. Results Among 1,607 patients, the ordinal mRS was more strongly related to 5-year mortality than both the 0–1/2–6 and 0–2/3–6 dichotomies (all p < 0.0001). Results were similar for 5-year disability, and 5-year care costs were also best captured by the ordinal model (change in mean absolute error vs age/sex: −$3,059 for ordinal, −$2,805 for 0–2/3–6, −$1,647 for 0–1/2–6). Two hundred forty-four (17.1%) 3-month survivors had premorbid mRS score >2 and 434 (30.5%) had mRS score >1; both proportions increased with female sex, socioeconomic deprivation, and age (all p < 0.0001). Conclusion The ordinal form of the 3-month mRS relates better to long-term outcomes and costs in survivors of ischemic stroke than either dichotomy. This finding favors using ordinal approaches in trials analyzing the mRS. Exclusion of patients with higher premorbid disability by use of dichotomous primary outcomes will also result in unrepresentative samples.
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Affiliation(s)
- Aravind Ganesh
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Ramon Luengo-Fernandez
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Rose M Wharton
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter M Rothwell
- From the Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
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Cassarly C, Martin RH, Chimowitz M, Peña EA, Ramakrishnan V, Palesch YY. Treatment effect on ordinal functional outcome using piecewise multistate Markov model with unobservable baseline: an application to the modified Rankin scale. J Biopharm Stat 2018; 29:82-97. [PMID: 29985739 DOI: 10.1080/10543406.2018.1489404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In clinical trials, longitudinally assessed ordinal outcomes are commonly dichotomized and only the final measure is used for primary analysis, partly for ease of clinical interpretation. Dichotomization of the ordinal scale and failure to utilize the repeated measures can reduce statistical power. Additionally, in certain emergent settings, the same measure cannot be assessed at baseline prior to treatment. For such a data set, a piecewise-constant multistate Markov model that incorporates a latent model for the unobserved baseline measure is proposed. These models can be useful in analyzing disease history data and are advantageous in clinical applications where a disease process naturally moves through increasing stages of severity. Two examples are provided using acute stroke clinical trials data. Conclusions drawn in this article are consistent with those from the primary analysis for treatment effect in both of the motivating examples. Use of these models allows for a more refined examination of treatment effect and describes the movement between health states from baseline to follow-up visits which may provide more clinical insight into the treatment effect.
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Affiliation(s)
- Christy Cassarly
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA.,b Department of Otolaryngology-Head & Neck Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Renee' H Martin
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
| | - Marc Chimowitz
- c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Edsel A Peña
- d Department of Statistics , University of South Carolina , Columbia , SC , USA
| | - Viswanathan Ramakrishnan
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
| | - Yuko Y Palesch
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
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COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation 2018; 127:147-163. [DOI: 10.1016/j.resuscitation.2018.03.022] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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36
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Intrathecal Injection of Allogenic Bone Marrow-Derived Mesenchymal Stromal Cells in Treatment of Patients with Severe Ischemic Stroke: Study Protocol for a Randomized Controlled Observer-Blinded Trial. Transl Stroke Res 2018; 10:170-177. [DOI: 10.1007/s12975-018-0634-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 12/13/2022]
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Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Böttiger BW, Brooks A, Castrén M, Ong ME, Hazinski MF, Koster RW, Lilja G, Long J, Monsieurs KG, Morley PT, Morrison L, Nichol G, Oriolo V, Saposnik G, Smyth M, Spearpoint K, Williams B, Perkins GD. COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation 2018; 137:e783-e801. [PMID: 29700122 DOI: 10.1161/cir.0000000000000562] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scientists, and the International Liaison Committee on Resuscitation, sought to develop a consensus core outcome set for cardiac arrest for effectiveness trials. Core outcome sets are primarily intended for large, randomized clinical effectiveness trials (sometimes referred to as pragmatic trials or phase III/IV trials) rather than for pilot or efficacy studies. A systematic review of the literature combined with qualitative interviews among cardiac arrest survivors was used to generate a list of potential outcome domains. This list was prioritized through a Delphi process, which involved clinicians, patients, and their relatives/partners. An international advisory panel narrowed these down to 3 core domains by debate that led to consensus. The writing group refined recommendations for when these outcomes should be measured and further characterized relevant measurement tools. Consensus emerged that a core outcome set for reporting on effectiveness studies of cardiac arrest (COSCA) in adults should include survival, neurological function, and health-related quality of life. This should be reported as survival status and modified Rankin scale score at hospital discharge, at 30 days, or both. Health-related quality of life should be measured with ≥1 tools from Health Utilities Index version 3, Short-Form 36-Item Health Survey, and EuroQol 5D-5L at 90 days and at periodic intervals up to 1 year after cardiac arrest, if resources allow.
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Boers AMM, Sales Barros R, Jansen IGH, Berkhemer OA, Beenen LFM, Menon BK, Dippel DWJ, van der Lugt A, van Zwam WH, Roos YBWEM, van Oostenbrugge RJ, Slump CH, Majoie CBLM, Marquering HA. Value of Quantitative Collateral Scoring on CT Angiography in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2018; 39:1074-1082. [PMID: 29674417 DOI: 10.3174/ajnr.a5623] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/09/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Many studies have emphasized the relevance of collateral flow in patients presenting with acute ischemic stroke. Our aim was to evaluate the relationship of the quantitative collateral score on baseline CTA with the outcome of patients with acute ischemic stroke and test whether the timing of the CTA acquisition influences this relationship. MATERIALS AND METHODS From the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) data base, all baseline thin-slice CTA images of patients with acute ischemic stroke with intracranial large-vessel occlusion were retrospectively collected. The quantitative collateral score was calculated as the ratio of the vascular appearance of both hemispheres and was compared with the visual collateral score. Primary outcomes were 90-day mRS score and follow-up infarct volume. The relation with outcome and the association with treatment effect were estimated. The influence of the CTA acquisition phase on the relation of collateral scores with outcome was determined. RESULTS A total of 442 patients were included. The quantitative collateral score strongly correlated with the visual collateral score (ρ = 0.75) and was an independent predictor of mRS (adjusted odds ratio = 0.81; 95% CI, .77-.86) and follow-up infarct volume (exponent β = 0.88; P < .001) per 10% increase. The quantitative collateral score showed areas under the curve of 0.71 and 0.69 for predicting functional independence (mRS 0-2) and follow-up infarct volume of >90 mL, respectively. We found significant interaction of the quantitative collateral score with the endovascular therapy effect in unadjusted analysis on the full ordinal mRS scale (P = .048) and on functional independence (P = .049). Modification of the quantitative collateral score by acquisition phase on outcome was significant (mRS: P = .004; follow-up infarct volume: P < .001) in adjusted analysis. CONCLUSIONS Automated quantitative collateral scoring in patients with acute ischemic stroke is a reliable and user-independent measure of the collateral capacity on baseline CTA and has the potential to augment the triage of patients with acute stroke for endovascular therapy.
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Affiliation(s)
- A M M Boers
- From the Departments of Biomedical Engineering and Physics (A.M.M.B., R.S.B., I.G.H.J., H.A.M.) .,Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.).,Department of Robotics and Mechatronics (A.M.M.B., C.H.S.)
| | - R Sales Barros
- From the Departments of Biomedical Engineering and Physics (A.M.M.B., R.S.B., I.G.H.J., H.A.M.)
| | - I G H Jansen
- From the Departments of Biomedical Engineering and Physics (A.M.M.B., R.S.B., I.G.H.J., H.A.M.).,Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.)
| | - O A Berkhemer
- Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.)
| | - L F M Beenen
- Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.)
| | - B K Menon
- Department of Clinical Neurosciences (B.K.M.), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | | | - A van der Lugt
- Radiology (A.v.d.L.), Erasmus MC, Rotterdam, the Netherlands
| | - W H van Zwam
- Department of Radiology (W.H.v.Z.), Maastricht UMC, Maastricht, the Netherlands
| | - Y B W E M Roos
- Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - R J van Oostenbrugge
- Department of Neurology (R.J.v.O.), Maastricht UMC and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - C H Slump
- Department of Robotics and Mechatronics (A.M.M.B., C.H.S.).,MIRA Institute for Biomedical Engineering and Technical Medicine (C.H.S.), University of Twente, Enschede, the Netherlands
| | - C B L M Majoie
- Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.)
| | - H A Marquering
- From the Departments of Biomedical Engineering and Physics (A.M.M.B., R.S.B., I.G.H.J., H.A.M.).,Radiology and Nuclear Medicine (A.M.M.B., I.G.H.J., O.A.B., L.F.M.B., C.B.L.M.M., H.A.M.)
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Boers AMM, Jansen IGH, Beenen LFM, Devlin TG, San Roman L, Heo JH, Ribó M, Brown S, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Lingsma HF, van Zwam WH, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, van Oostenbrugge RJ, Menon BK, Donnan GA, Mas JL, Roos YBWEM, Oppenheim C, van der Lugt A, Dowling RJ, Hill MD, Davalos A, Moulin T, Agrinier N, Demchuk AM, Lopes DK, Aja Rodríguez L, Dippel DWJ, Campbell BCV, Mitchell PJ, Al-Ajlan FS, Jovin TG, Madigan J, Albers GW, Soize S, Guillemin F, Reddy VK, Bracard S, Blasco J, Muir KW, Nogueira RG, White PM, Goyal M, Davis SM, Marquering HA, Majoie CBLM. Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials. J Neurointerv Surg 2018; 10:1137-1142. [DOI: 10.1136/neurintsurg-2017-013724] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/04/2022]
Abstract
BackgroundFollow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.ObjectiveTo examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.MethodsData of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.ResultsOf 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).ConclusionsIn patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.
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Bornstein NM, Guekht A, Vester J, Heiss WD, Gusev E, Hömberg V, Rahlfs VW, Bajenaru O, Popescu BO, Muresanu D. Safety and efficacy of Cerebrolysin in early post-stroke recovery: a meta-analysis of nine randomized clinical trials. Neurol Sci 2017; 39:629-640. [PMID: 29248999 PMCID: PMC5884916 DOI: 10.1007/s10072-017-3214-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
Abstract
This meta-analysis combines the results of nine ischemic stroke trials, assessing efficacy of Cerebrolysin on global neurological improvement during early post-stroke period. Cerebrolysin is a parenterally administered neuropeptide preparation approved for treatment of stroke. All included studies had a prospective, randomized, double-blind, placebo-controlled design. The patients were treated with 30–50 ml Cerebrolysin once daily for 10–21 days, with treatment initiation within 72 h after onset of ischemic stroke. For five studies, original analysis data were available for meta-analysis (individual patient data analysis); for four studies, aggregate data were used. The combination by meta-analytic procedures was pre-planned and the methods of synthesis were pre-defined under blinded conditions. Search deadline for the present meta-analysis was December 31, 2016. The nonparametric Mann-Whitney (MW) effect size for National Institutes of Health Stroke Scale (NIHSS) on day 30 (or 21), combining the results of nine randomized, controlled trials by means of the robust Wei-Lachin pooling procedure (maximin-efficient robust test), indicated superiority of Cerebrolysin as compared with placebo (MW 0.60, P < 0.0001, N = 1879). The combined number needed to treat for clinically relevant changes in early NIHSS was 7.7 (95% CI 5.2 to 15.0). The additional full-scale ordinal analysis of modified Rankin Scale at day 90 in moderate to severe patients resulted in MW 0.61 with statistical significance in favor of Cerebrolysin (95% CI 0.52 to 0.69, P = 0.0118, N = 314). Safety aspects were comparable to placebo. Our meta-analysis confirms previous evidence that Cerebrolysin has a beneficial effect on early global neurological deficits in patients with acute ischemic stroke.
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Affiliation(s)
- Natan M Bornstein
- Shaare Zedek Medical Center, Jerusalem, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alla Guekht
- Russian National Research Medical University and Moscow Research and Clinical Center for Neuropsychiatry, Ul. Donskaya 43, Moscow, 115419, Russia
| | - Johannes Vester
- Department of Biometry and Clinical Research, IDV Data Analysis and Study Planning, Konrad-Zuse-Bogen 17, 82152, Krailling, Germany
| | - Wolf-Dieter Heiss
- Max Planck Institute for Metabolism Research, Gleueler Street 50, 50931, Cologne, Germany
| | - Eugene Gusev
- Russian National Research Medical University, Moscow, Russia
| | - Volker Hömberg
- Department of Neurology, SRH Gesundheitszentrum Bad Wimpfen GmbH, Bad Wimpfen, Germany
| | - Volker W Rahlfs
- Department of Biometry and Clinical Research, IDV Data Analysis and Study Planning, Konrad-Zuse-Bogen 17, 82152, Krailling, Germany
| | - Ovidiu Bajenaru
- Department of Neurology, "Carol Davila" University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, 050474, Bucharest, Romania
| | - Bogdan O Popescu
- Department of Neurology, "Carol Davila" University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, 050474, Bucharest, Romania.,Laboratory of Molecular Biology, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Dafin Muresanu
- Department of Clinical Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Victor Babes Street No. 8, 400012, Cluj-Napoca, Romania. .,"RoNeuro" Institute for Neurological Research and Diagnostic, 37 Mircea Eliade Street, 400364, Cluj-Napoca, Romania.
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Al-Ajlan FS, Al Sultan AS, Minhas P, Assis Z, de Miquel MA, Millán M, San Román L, Tomassello A, Demchuk AM, Jovin TG, Cuadras P, Dávalos A, Goyal M, Menon BK. Posttreatment Infarct Volumes when Compared with 24-Hour and 90-Day Clinical Outcomes: Insights from the REVASCAT Randomized Controlled Trial. AJNR Am J Neuroradiol 2017; 39:107-110. [PMID: 29170266 DOI: 10.3174/ajnr.a5463] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/16/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy has become the standard of care for patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi. Our aim was to determine whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in posttreatment infarct volume in the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) trial. MATERIALS AND METHODS The REVASCAT trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 206 enrolled subjects (endovascular treatment, n = 103; control, n = 103), posttreatment infarct volume was measured in 204 subjects. Posttreatment infarct volumes were compared with treatment assignment and recanalization status. Appropriate statistical models were used to assess the relationship among baseline clinical and imaging variables, posttreatment infarct volume, the 24-hour NIHSS score, and functional status with the 90-day modified Rankin Scale score. RESULTS The median posttreatment infarct volume in all subjects was 23.7 mL (interquartile range = 68.9 mL) and 16.3 mL (interquartile range = 50.2 mL) in the endovascular treatment arm and 38.6 mL (interquartile range = 74.9 mL) in the control arm (P = .02 for endovascular treatment versus control subjects). Baseline NIHSS (P < .01), site of occlusion (P < .03), baseline NCCT ASPECTS (P < .01), and recanalization status (P = .02) were independently associated with posttreatment infarct volume. Baseline NIHSS (P < .01), time from symptom onset to randomization (P = .02), treatment type (P = .04), and recanalization status (P < .01) were independently associated with the 24-hour NIHSS scores. The 24-hour NIHSS score strongly mediated the relationship between treatment type and 90-day mRS (P < .01 for indirect effect when adjusted for age), while posttreatment infarct volume did not (P = .26). CONCLUSIONS Endovascular treatment saves brain and improves 90-day clinical outcomes primarily through a beneficial effect on the 24-hour stroke severity.
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Affiliation(s)
- F S Al-Ajlan
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosciences at King Faisal Specialist Hospital and Research Centre (F.S.A.-A.), Riyadh, Saudi Arabia
| | - A S Al Sultan
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P Minhas
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Z Assis
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M A de Miquel
- Stroke Unit (M.A.d.M.), Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Millán
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - L San Román
- Stroke Unit (L.S.R.), Neurology Department, Hospital Clínic, Barcelona, Spain
| | - A Tomassello
- Stroke Unit (A.T.), Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - A M Demchuk
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T G Jovin
- Stroke Institute (T.G.J.), Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - P Cuadras
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - A Dávalos
- Stroke Unit (M.M., P.C., A.D.), Department of Neurosciences and Department of Radiology, Hospital Germans Trias, Universitat Autosome de Barcelona, Badalona (Barcelona), Spain
| | - M Goyal
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences and Department of Radiology (F.S.A.-A., A.S.A.S., P.M., Z.A., A.M.D., M.G., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Yoshimura S, Uchida K, Daimon T, Takashima R, Kimura K, Morimoto T, Tanada S, Iida T, Kuroda J, Nose A, Tatebayashi K, Shimizu F, Tsudaka S, Takeuchi M, Hiyama N, Oki Y, Hagii J, Saito S, Matsumoto T, Tanaka Y, Kuramoto Y, Mikami K, Shinoda N, Shimo D, Soneda J, Tokuda K, Matsuda K, Hiroto K, Yamaura I, Okada T, Hirano T, Kuwayama N, Teramukai S. Randomized Controlled Trial of Early Versus Delayed Statin Therapy in Patients With Acute Ischemic Stroke. Stroke 2017; 48:3057-3063. [DOI: 10.1161/strokeaha.117.017623] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Several studies suggested that statins during hospitalization were associated with better disability outcomes in patients with acute ischemic stroke, but only 1 small randomized trial is available.
Methods—
We conducted a multicenter, open-label, randomized controlled trial in patients with acute ischemic strokes in 11 hospitals in Japan. Patients with acute ischemic stroke and dyslipidemia randomly received statins within 24 hours after admission in the early group or on the seventh day in the delayed group, in a 1:1 ratio. Statins were administered for 12 weeks. The primary outcome was patient disability assessed by modified Rankin Scale at 90 days.
Results—
A total of 257 patients were randomized and analyzed (early 131, delayed 126). At 90 days, modified Rankin Scale score distribution did not differ between groups (
P
=0.68), and the adjusted common odds ratio of the early statin group was 0.84 (95% confidence interval, 0.53–1.3;
P
=0.46) compared with the delayed statin group. There were 3 deaths at 90 days (2 in the early group, 1 in the delayed group) because of malignancy. Ischemic stroke recurred in 9 patients (6.9%) in the early group and 5 patients (4.0%) in the delayed group. The safety profile was similar between groups.
Conclusions—
Our randomized trial involving patients with acute ischemic stroke and dyslipidemia did not show any superiority of early statin therapy within 24 hours of admission compared with delayed statin therapy 7 days after admission to alleviate the degree of disability at 90 days after onset.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02549846.
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Affiliation(s)
- Shinichi Yoshimura
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
| | - Kazutaka Uchida
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
| | - Takashi Daimon
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
| | - Ryuzo Takashima
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
| | - Kazuhiro Kimura
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
| | - Takeshi Morimoto
- From the Department of Neurosurgery (S.Y., K.U.), Department of Clinical Epidemiology (K.U., T.M.), Center for Clinical Research and Education (T.D., T.M.), and Department of Biostatistics (T.D.), Hyogo College of Medicine, Nishinomiya, Hyogo, Japan; and Medical Affairs Department, Shionogi & Co, Ltd, Osaka, Japan (R.T., K.K.)
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Cassarly C, Martin RH, Chimowitz M, Peña EA, Ramakrishnan V, Palesch YY. Comparison of multistate Markov modeling with contemporary outcomes in a reanalysis of the NINDS tissue plasminogen activator for acute ischemic stroke treatment trial. PLoS One 2017; 12:e0187050. [PMID: 29073195 PMCID: PMC5658159 DOI: 10.1371/journal.pone.0187050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 10/12/2017] [Indexed: 11/19/2022] Open
Abstract
Historically, ordinal measures of functional outcome have been dichotomized for the primary analysis in acute stroke therapy trials. A number of alternative methods to analyze the ordinal scales have been proposed, with an emphasis on maintaining the ordinal structure as much as possible. In addition, despite the availability of longitudinal outcome data in many trials, the primary analysis consists of a single endpoint. Inclusion of information about the course of disease progression allows for a more complete understanding of the treatment effect. Multistate Markov modeling, which allows for the full ordinal scale to be analyzed longitudinally, is compared with previously suggested analytic techniques for the ordinal modified Rankin Scale (dichotomous-logistic regression; continuous-linear regression; ordinal- shift analysis, proportional odds model, partial proportional odds model, adjacent categories logit model; sliding dichotomy; utility weights; repeated measures). In addition, a multistate Markov model utilizing an estimate of the unobservable baseline outcome derived from principal component analysis is compared Each of the methods is used to re-analyze the National Institute of Neurological Diseases and Stroke tissue plasminogen activator study which showed a consistently significant effect of tissue plasminogen activator using a global test of four dichotomized outcomes in the analysis of the primary outcome at 90 days post-stroke in the primary analysis. All methods detected a statistically significant treatment effect except the multistate Markov model without predicted baseline (p = 0.053). This provides support for the use of the estimated baseline in the multistate Markov model since the treatment effect is able to be detected with its inclusion. Multistate Markov modeling allows for a more refined examination of treatment effect and describes the movement between modified Rankin Scale states over time which may provide more clinical insight into the treatment effect. Multistate Markov models are feasible and desirable in describing treatment effect in acute stroke therapy trials.
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Affiliation(s)
- Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, United States of America
- * E-mail:
| | - Renee’ H. Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Marc Chimowitz
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Edsel A. Peña
- Department of Statistics, University of South Carolina, Columbia, South Carolina, United States of America
| | - Viswanathan Ramakrishnan
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Yuko Y. Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
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44
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Gon Y, Todo K, Mochizuki H, Sakaguchi M. Cancer is an independent predictor of poor outcomes in patients following intracerebral hemorrhage. Eur J Neurol 2017; 25:128-134. [PMID: 28895254 DOI: 10.1111/ene.13456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/07/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Patients with cancer have been reported to have poorer outcomes following intracerebral hemorrhage (ICH) than those without cancer, but the findings were not consistent between studies. The aim of this study was to test the hypothesis that cancer is associated with poor outcomes following ICH. METHODS In all, 3137 consecutive patients admitted to the stroke unit of Osaka University Hospital were reviewed. Patients diagnosed with ICH were extracted and divided into two groups according to the presence of cancer. ICH characteristics were compared between the groups. The outcomes were measured using the 30-day and 90-day modified Rankin Scale (mRS). RESULTS Amongst the 399 ICH patients (37.1% women; median age 66 years), the frequency of cancer was 15.3%. Of these, 70.5% of patients had distant metastatic cancers. Compared to controls, cancer patients were comparable in the Glasgow Coma Scale, hematoma volume and the frequency of infratentorial location and intraventricular hemorrhage extension, but had poorer outcomes following ICH. Ordinal logistic regression analysis revealed that cancer was independently associated with poor outcomes following ICH (odds ratio 5.14; 95% confidence interval 2.63-10.06). Adjustment was made for the covariates age, sex, time from onset to admission, prior use of antithrombotic agents, pre-stroke mRS, Glasgow Coma Scale, hematoma volume, infratentorial location and intraventricular hemorrhage extension. When the analysis was performed using data from individuals with localized cancer, the effect remained significant after assessment with 90-day mRS but not after that with 30-day mRS. CONCLUSIONS The results suggest that cancer, especially distant metastatic cancer, is an independent predictor of poorer outcomes following ICH.
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Affiliation(s)
- Y Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - K Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - H Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - M Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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45
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Borst J, Berkhemer OA, Santos EMM, Yoo AJ, den Blanken M, Roos YBWEM, van Bavel E, van Zwam WH, van Oostenbrugge RJ, Lingsma HF, van der Lugt A, Dippel DWJ, Marquering HA, Majoie CBLM. Value of Thrombus CT Characteristics in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:1758-1764. [PMID: 28751519 DOI: 10.3174/ajnr.a5331] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 05/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thrombus CT characteristics might be useful for patient selection for intra-arterial treatment. Our objective was to study the association of thrombus CT characteristics with outcome and treatment effect in patients with acute ischemic stroke. MATERIALS AND METHODS We included 199 patients for whom thin-section NCCT and CTA within 30 minutes from each other were available in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) study. We assessed the following thrombus characteristics: location, distance from ICA terminus to thrombus, length, volume, absolute and relative density on NCCT, and perviousness. Associations of thrombus characteristics with outcome were estimated with univariable and multivariable ordinal logistic regression as an OR for a shift toward better outcome on the mRS. Interaction terms were used to investigate treatment-effect modification by thrombus characteristics. RESULTS In univariate analysis, only the distance from the ICA terminus to the thrombus, length of >8 mm, and perviousness were associated with functional outcome. Relative thrombus density on CTA was independently associated with functional outcome with an adjusted common OR of 1.21 per 10% (95% CI, 1.02-1.43; P = .029). There was no treatment-effect modification by any of the thrombus CT characteristics. CONCLUSIONS In our study on patients with large-vessel occlusion of the anterior circulation, CT thrombus characteristics appear useful for predicting functional outcome. However, in our study cohort, the effect of intra-arterial treatment was independent of the thrombus CT characteristics. Therefore, no arguments were provided to select patients for intra-arterial treatment using thrombus CT characteristics.
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Affiliation(s)
- J Borst
- From the Departments of Radiology (J.B., O.A.B., E.M.M.S., H.A.M., C.B.L.M.M.)
| | - O A Berkhemer
- From the Departments of Radiology (J.B., O.A.B., E.M.M.S., H.A.M., C.B.L.M.M.).,Neurology (O.A.B., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - E M M Santos
- From the Departments of Radiology (J.B., O.A.B., E.M.M.S., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (E.M.M.S., M.d.B., E.v.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.,Radiology (E.M.M.S., A.v.d.L.).,Medical Informatics (E.M.M.S.)
| | - A J Yoo
- Department of Radiology (A.J.Y.), Texas Stroke Institute, Plano, Texas
| | - M den Blanken
- Biomedical Engineering and Physics (E.M.M.S., M.d.B., E.v.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | | | - E van Bavel
- Biomedical Engineering and Physics (E.M.M.S., M.d.B., E.v.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | | | - R J van Oostenbrugge
- Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - D W J Dippel
- Neurology (O.A.B., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology (J.B., O.A.B., E.M.M.S., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (E.M.M.S., M.d.B., E.v.B., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - C B L M Majoie
- From the Departments of Radiology (J.B., O.A.B., E.M.M.S., H.A.M., C.B.L.M.M.)
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46
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Dutta D, Hellier K, Obaid M, Deering A. Evaluation of a single centre stroke service reconfiguration - the impact of transition from a combined (acute and rehabilitation) stroke unit to a hyperacute model of stroke care. Future Healthc J 2017; 4:99-104. [PMID: 31098443 PMCID: PMC6502622 DOI: 10.7861/futurehosp.4-2-99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We reorganised the combined (acute and rehab) stroke unit (SU) at Gloucestershire Royal Hospital into a hyperacute stroke unit (HASU) and a rehab SU where patients are moved after spending about 72 hours on HASU. Continuous monitoring of physiological variables was introduced and consultant job plans were reorganised to provide a HASU physician of the week model with enhanced 7-day senior presence along with redistribution of junior medical staff. Sentinel Stroke National Audit Programme (SSNAP) data for 14 months preceding the reorganisation (n=1,049) and 14 months after (n=974) were accessed for outcomes. More patients were admitted directly to the HASU with favourable reductions in time to computerised tomography scanning and stroke consultant assessment after the change. There were significant reductions in length of stay, pneumonia and urinary tract infections at 7 days and a favourable shift in modified Rankin scores (odds ratio 1.60, 95% confidence interval 1.36-1.89, p<0.001) on discharge from hospital.
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Affiliation(s)
- Dipankar Dutta
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Kate Hellier
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Mudhar Obaid
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
| | - Arnold Deering
- Stroke Service, Gloucestershire Royal Hospital, Gloucester, UK
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47
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Mistry EA, Mistry AM, Nakawah MO, Khattar NK, Fortuny EM, Cruz AS, Froehler MT, Chitale RV, James RF, Fusco MR, Volpi JJ. Systolic Blood Pressure Within 24 Hours After Thrombectomy for Acute Ischemic Stroke Correlates With Outcome. J Am Heart Assoc 2017; 6:JAHA.117.006167. [PMID: 28522673 PMCID: PMC5524120 DOI: 10.1161/jaha.117.006167] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Current guidelines suggest treating blood pressure above 180/105 mm Hg during the first 24 hours in patients with acute ischemic stroke undergoing any form of recanalization therapy. Currently, no studies exist to guide blood pressure management in patients with stroke treated specifically with mechanical thrombectomy. We aimed to determine the association between blood pressure parameters within the first 24 hours after mechanical thrombectomy and patient outcomes. Methods and Results We retrospectively studied a consecutive sample of adult patients who underwent mechanical thrombectomy for acute ischemic stroke of the anterior cerebral circulation at 3 institutions from March 2015 to October 2016. We collected the values of maximum, minimum, and average values of systolic blood pressure, diastolic blood pressure, and mean arterial pressures in the first 24 hours after mechanical thrombectomy. Primary and secondary outcomes were patients’ functional status at 90 days measured on the modified Rankin scale and the incidence and severity of intracranial hemorrhages within 48 hours. Associations were explored using an ordered multivariable logistic regression analyses. A total of 228 patients were included (mean age 65.8±14.3; 104 males, 45.6%). Maximum systolic blood pressure independently correlated with a worse 90‐day modified Rankin scale and hemorrhagic complications within 48 hours (adjusted odds ratio=1.02 [1.01–1.03], P=0.004; 1.02 [1.01–1.04], P=0.002; respectively) in multivariable analyses, after adjusting for several possible confounders. Conclusions Higher peak values of systolic blood pressure independently correlated with worse 90‐day modified Rankin scale and a higher rate of hemorrhagic complications. Further prospective studies are warranted to identify whether systolic blood pressure is a therapeutic target to improve outcomes.
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Affiliation(s)
- Eva A Mistry
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX
| | | | | | - Nicolas K Khattar
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY
| | - Enzo M Fortuny
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY
| | - Aurora S Cruz
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN
| | - Rohan V Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN
| | - Robert F James
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY
| | - Matthew R Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN
| | - John J Volpi
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX
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48
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Park HK, Chung JW, Hong JH, Jang MU, Noh HD, Park JM, Kang K, Lee SJ, Ko Y, Kim JG, Cha JK, Kim DH, Nah HW, Han MK, Kim BJ, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Lee BC, Yu KH, Oh MS, Cho KH, Kim JT, Kim DE, Ryu WS, Choi JC, Kim WJ, Shin DI, Yeo MJ, Sohn SI, Lee JS, Lee J, Yoon BW, Bae HJ. Preceding Intravenous Thrombolysis in Patients Receiving Endovascular Therapy. Cerebrovasc Dis 2017; 44:51-58. [DOI: 10.1159/000471492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/06/2016] [Indexed: 11/19/2022] Open
Abstract
Background: The beneficial effects of endovascular therapy (EVT) in acute ischemic stroke have been demonstrated in recent clinical trials using new-generation thrombectomy devices. However, the comparative effectiveness and safety of preceding intravenous thrombolysis (IVT) in this population has rarely been evaluated. Methods: From a prospective multicenter stroke registry database in Korea, we identified patients with acute ischemic stroke who were treated with EVT within 8 h of onset and admitted to 14 participating centers during 2008-2013. The primary outcome was a modified Rankin Scale (mRS) score at 3 months. Major secondary outcomes were successful recanalization defined as a modified Treatment in Cerebral Ischemia score of 2b-3, functional independence (mRS score 0-2), mortality at 3 months, and symptomatic hemorrhagic transformation (SHT) during hospitalization. Multivariable logistic regression analyses using generalized linear mixed models were performed to estimate the adjusted odds ratios (ORs) of preceding IVT. Results: Of the 639 patients (male, 61%; age 69 ± 12; National Institutes of Health Stroke Scale score of 15 [11-19]) who met the eligibility criteria, 458 received preceding IVT. These patients showed lower mRS scores (adjusted common OR, 1.38 [95% CI 0.98-1.96]). Preceding IVT was associated with successful recanalization (1.96 [1.23-3.11]) and reduced 3-month mortality (0.58 [0.35-0.97]) but not with SHT (0.96 [0.48-1.93]). Conclusion: In patients treated with EVT within 8 of acute ischemic stroke onset, preceding IVT may enhance survival and successful recanalization without additional risk of SHT, and mitigate disability at 3 months.
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49
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Dargazanli C, Consoli A, Gory B, Blanc R, Labreuche J, Preda C, Bourdain F, Decroix JP, Redjem H, Ciccio G, Mazighi M, Smajda S, Desilles JP, Riva R, Labeyrie PE, Coskun O, Rodesch G, Turjman F, Piotin M, Lapergue B. Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation? Cerebrovasc Dis 2017; 43:305-312. [DOI: 10.1159/000468995] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 02/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.
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50
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Phan TG, Chen J, Beare R, Ma H, Clissold B, Van Ly J, Srikanth V. Classification of Different Degrees of Disability Following Intracerebral Hemorrhage: A Decision Tree Analysis from VISTA-ICH Collaboration. Front Neurol 2017; 8:64. [PMID: 28293215 PMCID: PMC5329022 DOI: 10.3389/fneur.2017.00064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/13/2017] [Indexed: 12/04/2022] Open
Abstract
Background and purpose Prognostication following intracerebral hemorrhage (ICH) has focused on poor outcome at the expense of lumping together mild and moderate disability. We aimed to develop a novel approach at classifying a range of disability following ICH. Methods The Virtual International Stroke Trial Archive collaboration database was searched for patients with ICH and known volume of ICH on baseline CT scans. Disability was partitioned into mild [modified Rankin Scale (mRS) at 90 days of 0–2], moderate (mRS = 3–4), and severe disabilities (mRS = 5–6). We used binary and trichotomy decision tree methodology. The data were randomly divided into training (2/3 of data) and validation (1/3 data) datasets. The area under the receiver operating characteristic curve (AUC) was used to calculate the accuracy of the decision tree model. Results We identified 957 patients, age 65.9 ± 12.3 years, 63.7% males, and ICH volume 22.6 ± 22.1 ml. The binary tree showed that lower ICH volume (<13.7 ml), age (<66.5 years), serum glucose (<8.95 mmol/l), and systolic blood pressure (<170 mm Hg) discriminate between mild versus moderate-to-severe disabilities with AUC of 0.79 (95% CI 0.73–0.85). Large ICH volume (>27.9 ml), older age (>69.5 years), and low Glasgow Coma Scale (<15) classify severe disability with AUC of 0.80 (95% CI 0.75–0.86). The trichotomy tree showed that ICH volume, age, and serum glucose can separate mild, moderate, and severe disability groups with AUC 0.79 (95% CI 0.71–0.87). Conclusion Both the binary and trichotomy methods provide equivalent discrimination of disability outcome after ICH. The trichotomy method can classify three categories at once, whereas this action was not possible with the binary method. The trichotomy method may be of use to clinicians and trialists for classifying a range of disability in ICH.
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Affiliation(s)
- Thanh G Phan
- Neurosciences, Monash Health , Melbourne, VIC , Australia
| | - Jian Chen
- Department of Medicine, School of Clinical Sciences, Monash University , Clayton, VIC , Australia
| | - Richard Beare
- Department of Medicine, School of Clinical Sciences, Monash University , Clayton, VIC , Australia
| | - Henry Ma
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Benjamin Clissold
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - John Van Ly
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Velandai Srikanth
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, Central Clinical School, Monash University, Frankston, VIC, Australia
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