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Oliveira M, Barros P, Rodrigues M, Ribeiro M, Afreixo V, Gregório T. Endovascular therapy for posterior cerebral artery occlusion: systematic review with meta-analysis. Intern Emerg Med 2024; 19:1143-1150. [PMID: 38600317 DOI: 10.1007/s11739-024-03581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/07/2024] [Indexed: 04/12/2024]
Abstract
Endovascular therapy (EVT) is a highly effective stroke treatment, but trials validating this intervention did not include patients with posterior cerebral artery (PCA) occlusion. The aim of this systematic review with meta-analysis was to assess the efficacy and safety of EVT for acute PCA occlusion. PubMed, Scopus, ISI, and CENTRAL were searched for studies assessing EVT in adult patients with PCA occlusion. Outcomes of interest were recanalization, symptomatic intracerebral haemorrhage (sICH), mortality, functional independence, and excellent functional outcome at 90 days. Frequencies and odds ratios (ORs) were pooled using random effect models and heterogeneity was measured using the I2 statistic and explored by means of meta-regression. Fifteen studies were included, all observational. Recanalization rates were high [81%, 95% CI (73-88%)] and sICH rates low [2%, 95% CI (1-4%)]. Heterogeneity was high for recanalization (I2 = 80%) but not for sICH, and not accounted for by any of the moderators tested. Compared to best medical treatment, EVT was associated with higher chances of sICH [OR = 2.04, 95% CI (1.12-3.71)] and no effect in functional independence [OR = 0.98, 95% CI (0.63-1.54)], with a tendency to higher chances of excellent functional outcome [OR = 1.29, 95% CI (0.90-1.86)] and mortality [OR = 1.56, 95% CI (0.84-2.90)]. EVT for acute PCA occlusion is technically feasible but associated with higher chance of sICH. There is no evidence to support this treatment to achieve higher rates of functional independence, but other gains that can impact patients' quality of life cannot be excluded. More studies are required with robust design, better patient selection, and comprehensive outcome evaluation.
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Affiliation(s)
- Marta Oliveira
- Department of Internal Medicine, Hospital CUF Porto, Estr. da Circunvalação 14341, 4100-180, Porto, Portugal.
| | - Pedro Barros
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Marta Rodrigues
- Cerebrovascular Interventional Neuroradiology Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Manuel Ribeiro
- Cerebrovascular Interventional Neuroradiology Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Vera Afreixo
- Center for Research and Development in Mathematics and Applications, University of Aveiro. Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
| | - Tiago Gregório
- Stroke Unit, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia e Espinho EPE. Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
- CINTESIS, University of Porto. R. Dr. Plácido Costa, 4200-450, Porto, Portugal
- MEDCIDS, University of Porto. R. Dr. Plácido Costa, 4200-450, Porto, Portugal
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Uchida K, Rinkel LA, Ospel JM, Diprose WK, Goyal M. A systematic review of randomized controlled trials of endovascular therapy for stroke on mortality and disability. J Neurol Sci 2024; 460:122991. [PMID: 38579415 DOI: 10.1016/j.jns.2024.122991] [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: 01/11/2024] [Revised: 03/01/2024] [Accepted: 03/31/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) has become standard of care for patients with anterior circulation large vessel occlusion (LVO) stroke, with indications having recently expanded to late time-window and large ischemic core patients. There is conflicting evidence on whether EVT reduces mortality or only disability. We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effect of EVT on mortality and severe disability. METHODS We systematically searched PubMed, Web of Science, Scopus, and Embase on November 15, 2023, to identify phase 3 RCTs comparing EVT to best medical treatment (BMT) in patients with anterior circulation LVO stroke in a common effects meta-analysis. The primary outcome was mortality at 3 months. Secondary outcomes were moderately severe or severe disability (modified Rankin Scale (mRS) score 4-5) at 3 months. RESULTS 18 studies comparing EVT to BMT were included, with a total of 4309 patients; 2159 that were treated with EVT, and 2150 treated with BMT. Mortality was significantly lower in the EVT group than in the BMT group (odds ratio (OR): 0.81, 95% CI: 0.70-0.94). Proportions of moderately severe or severe disability (OR: 0.55, 95% CI: 0.48-0.62) were also significantly lower in patients treated with EVT. CONCLUSIONS This meta-analysis suggests that EVT reduces both mortality and moderately severe or severe disability in patients with anterior circulation LVO stroke.
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Affiliation(s)
- Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan; Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Leon A Rinkel
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Departments of Neurology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - William K Diprose
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada; Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mayank Goyal
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, AB, Canada.
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Pinckaers FME, Grutters JPC, Huijberts I, Gabrio A, Boogaarts HD, Postma AA, van Oostenbrugge RJ, van Zwam WH, Evers SMAA. Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:441-448. [PMID: 38244981 DOI: 10.1016/j.jval.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke. METHODS Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients. RESULTS 1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point. CONCLUSIONS The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.
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Affiliation(s)
- Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | | | - Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | | | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Health Services Research, Maastricht University, Maastricht, The Netherlands; Centre of Economic Evaluation and Machine Learning, Trimbos Institute, Utrecht, The Netherlands
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Westwood M, Ramaekers B, Grimm S, Armstrong N, Wijnen B, Ahmadu C, de Kock S, Noake C, Joore M. Software with artificial intelligence-derived algorithms for analysing CT brain scans in people with a suspected acute stroke: a systematic review and cost-effectiveness analysis. Health Technol Assess 2024; 28:1-204. [PMID: 38512017 PMCID: PMC11017149 DOI: 10.3310/rdpa1487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Artificial intelligence-derived software technologies have been developed that are intended to facilitate the review of computed tomography brain scans in patients with suspected stroke. Objectives To evaluate the clinical and cost-effectiveness of using artificial intelligence-derived software to support review of computed tomography brain scans in acute stroke in the National Health Service setting. Methods Twenty-five databases were searched to July 2021. The review process included measures to minimise error and bias. Results were summarised by research question, artificial intelligence-derived software technology and study type. The health economic analysis focused on the addition of artificial intelligence-derived software-assisted review of computed tomography angiography brain scans for guiding mechanical thrombectomy treatment decisions for people with an ischaemic stroke. The de novo model (developed in R Shiny, R Foundation for Statistical Computing, Vienna, Austria) consisted of a decision tree (short-term) and a state transition model (long-term) to calculate the mean expected costs and quality-adjusted life-years for people with ischaemic stroke and suspected large-vessel occlusion comparing artificial intelligence-derived software-assisted review to usual care. Results A total of 22 studies (30 publications) were included in the review; 18/22 studies concerned artificial intelligence-derived software for the interpretation of computed tomography angiography to detect large-vessel occlusion. No study evaluated an artificial intelligence-derived software technology used as specified in the inclusion criteria for this assessment. For artificial intelligence-derived software technology alone, sensitivity and specificity estimates for proximal anterior circulation large-vessel occlusion were 95.4% (95% confidence interval 92.7% to 97.1%) and 79.4% (95% confidence interval 75.8% to 82.6%) for Rapid (iSchemaView, Menlo Park, CA, USA) computed tomography angiography, 91.2% (95% confidence interval 77.0% to 97.0%) and 85.0 (95% confidence interval 64.0% to 94.8%) for Viz LVO (Viz.ai, Inc., San Fransisco, VA, USA) large-vessel occlusion, 83.8% (95% confidence interval 77.3% to 88.7%) and 95.7% (95% confidence interval 91.0% to 98.0%) for Brainomix (Brainomix Ltd, Oxford, UK) e-computed tomography angiography and 98.1% (95% confidence interval 94.5% to 99.3%) and 98.2% (95% confidence interval 95.5% to 99.3%) for Avicenna CINA (Avicenna AI, La Ciotat, France) large-vessel occlusion, based on one study each. These studies were not considered appropriate to inform cost-effectiveness modelling but formed the basis by which the accuracy of artificial intelligence plus human reader could be elicited by expert opinion. Probabilistic analyses based on the expert elicitation to inform the sensitivity of the diagnostic pathway indicated that the addition of artificial intelligence to detect large-vessel occlusion is potentially more effective (quality-adjusted life-year gain of 0.003), more costly (increased costs of £8.61) and cost-effective for willingness-to-pay thresholds of £3380 per quality-adjusted life-year and higher. Limitations and conclusions The available evidence is not suitable to determine the clinical effectiveness of using artificial intelligence-derived software to support the review of computed tomography brain scans in acute stroke. The economic analyses did not provide evidence to prefer the artificial intelligence-derived software strategy over current clinical practice. However, results indicated that if the addition of artificial intelligence-derived software-assisted review for guiding mechanical thrombectomy treatment decisions increased the sensitivity of the diagnostic pathway (i.e. reduced the proportion of undetected large-vessel occlusions), this may be considered cost-effective. Future work Large, preferably multicentre, studies are needed (for all artificial intelligence-derived software technologies) that evaluate these technologies as they would be implemented in clinical practice. Study registration This study is registered as PROSPERO CRD42021269609. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR133836) and is published in full in Health Technology Assessment; Vol. 28, No. 11. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | | | | | - Ben Wijnen
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | | | | | - Caro Noake
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
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Coleman CI, Concha M, Baker WL, Koch B, Lovelace B, Christoph MJ, Cohen AT. Agreement between 30-day and 90-day modified Rankin Scale score and utility-weighted modified Rankin Scale score in acute intracerebral hemorrhage: An analysis of ATACH-2 trial data. J Clin Neurosci 2024; 121:61-66. [PMID: 38364727 DOI: 10.1016/j.jocn.2024.02.009] [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: 12/06/2023] [Revised: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
The relationship between 30- and 90-day modified Rankin Scale (mRS) scores in intracerebral hemorrhage (ICH) patients was evaluated. This post hoc cohort analysis of the ATACH-2 trial included patients with acute ICH who were alive at 30 days and who had mRS scores reported at 30 and 90 days. The mRS score was then converted to a utility (EuroQol-5 Dimension-3 Level [EQ-5D-3L])-weighted mRS score. After adjustment of 30-day mRS score for key covariates using multivariable ordinal regression, the relationship between 30-day and observed 90-day functional outcome was assessed via absolute difference in the utility-weighted version. Of the 1000 trial subjects, 898 met inclusion criteria. This low-moderate severity ICH cohort had a median baseline GCS score of 15 and median hematoma volume of 9.7 mL. Observed 30-day mRS had the largest association with observed 90-day values (χ2 = 302.9, p < 0.0001). Patients generally either maintained the same mRS scores between 30 and 90 days (48 %) or experienced a 1-point (32 %) or 2-point (10 %) improvement by 90 days. The mean ± standard deviation (SD) EQ-5D-3L at 90 days was 0.67 ± 0.26. Following adjustment, the mean absolute difference between predicted and observed utility-weighted 90-day mRS scores was 0.006 ± 0.13 points and less than the estimated minimal clinically important difference of 0.13 points. The difference in average utility-weighted mRS scores at 30 and 90 days was not clinically relevant, suggesting 30-day score may be a reasonable proxy for 90-day values in patients with ICH when 90-day values are not available.
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Affiliation(s)
- Craig I Coleman
- University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269, USA; Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
| | - Mauricio Concha
- Sarasota Memorial Hospital, 1700 S Tamiami Trail, Sarasota, FL 34239, USA
| | - William L Baker
- University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269, USA; Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Bruce Koch
- AstraZeneca Pharmaceuticals, 1800 Concord Pike, Wilmington, DE 19083, USA
| | - Belinda Lovelace
- AstraZeneca Pharmaceuticals, 1800 Concord Pike, Wilmington, DE 19083, USA
| | - Mary J Christoph
- AstraZeneca Pharmaceuticals, 1800 Concord Pike, Wilmington, DE 19083, USA
| | - Alexander T Cohen
- Guy's and St. Thomas' Hospitals, King's College London, Westminster Bridge Road, London SE1 7EH, UK
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Ennab Vogel N, Wester P, Andersson Granberg T, Levin LÅ. Optimized density and locations of stroke centers for improved cost effectiveness of mechanical thrombectomy in patients with acute ischemic stroke. J Neurointerv Surg 2024; 16:156-162. [PMID: 37072170 PMCID: PMC10850679 DOI: 10.1136/jnis-2023-020299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/02/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs). METHODS This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis. RESULTS The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained. CONCLUSION The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Tobias Andersson Granberg
- Communications and Transport Systems, Linköping University Department of Science and Technology, Norrköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
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Chaisinanunkul N, Starkman S, Gornbein J, Hamilton S, Chatfield F, Conwit R, Saver JL. Staged use of ordinal and linear disability scales: a practical approach to granular assessment of acute stroke outcome. Front Neurol 2023; 14:1174686. [PMID: 37456628 PMCID: PMC10344771 DOI: 10.3389/fneur.2023.1174686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Background The modified Rankin Scale (mRS) assessment of global disability is the most common primary endpoint in acute stroke trials but lacks granularity (7 broad levels) and is ordinal (scale levels unknown distances apart), which constrains study power. Disability scales that are linear and continuous may better discriminate outcomes, but computerized administration in stroke patients is challenging. We, therefore, undertook to develop a staged use of an ordinal followed by a linear scale practical to use in multicenter trials. Methods Consecutive patients undergoing 3-month final visits in the NIH FAST-MAG phase 3 trial were assessed with the mRS followed by 15 mRS level-specific yes-no items of the Academic Medical Center Linear Disability Score (ALDS), a linear disability scale derived using item response theory. Results Among 55 patients, aged 71.2 (SD ± 14.2), 67% were men and the entry NIHSS was 10.7 (SD ± 9.5). At 90 days, the median mRS score was 3 (IQR, 1-4), and the median ALDS score was 78.8 (IQR, 3.3-100). ALDS scores correlated strongly with 90 days outcome measures, including the Barthel Index (r = 0.92), NIHSS (r = 0.87), and mRS (r = 0.94). ALDS scores also correlated modestly with entry NIHSS (r = 0.38). At 90 days, the ALDS showed greater scale granularity than the mRS, with fewer patients with identical values, 1.9 (SD ± 3.2) vs. 8.0 (SD ± 3.6), p < 0.001. When treatment effect magnitudes were small to moderate, projected trial sample size requirements were 2-12-fold lower when the ALDS rather than the mRS was used as the primary trial endpoint. Conclusion Among patients enrolled in an acute neuroprotective stroke trial, the ALDS showed strong convergent validity and superior discrimination characteristics compared with the modified Rankin Scale and increased projected trial power to detect clinically meaningful treatment benefits.
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Affiliation(s)
| | - Sidney Starkman
- Comprehensive Stroke Center and Departments of Emergency Medicine and Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jeffrey Gornbein
- Department of Biomathematics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Scott Hamilton
- Department of Neurology, Stanford University, Palo Alto, CA, United States
| | - Fiona Chatfield
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Robin Conwit
- National Institutes of Health, Bethesda, MD, United States
- Indiana University School of Medicine Department of Neurology, Indianapolis, IN, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
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Jakobsson J, Redebrandt HN, Tobieson L, Bartek J, Bartley A, Troberg E, Mirza S, Tsitsopoulos PP, Marklund N, Fahlström A. Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort. World Neurosurg 2023; 170:e351-e363. [PMID: 36368454 DOI: 10.1016/j.wneu.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation. METHODS A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed. RESULTS The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality. CONCLUSIONS Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.
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Affiliation(s)
- Johan Jakobsson
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Henrietta Nittby Redebrandt
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Lovisa Tobieson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jiri Bartek
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Bartley
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ebba Troberg
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Sadia Mirza
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neurosurgery, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, Lund, Sweden
| | - Andreas Fahlström
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Australia.
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Pożarowszczyk N, Kurkowska-Jastrzębska I, Sarzyńska-Długosz I, Nowak M, Karliński M. Reliability of the modified Rankin Scale in clinical practice of stroke units and rehabilitation wards. Front Neurol 2023; 14:1064642. [PMID: 36937517 PMCID: PMC10020493 DOI: 10.3389/fneur.2023.1064642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction The Modified Rankin Scale (mRS) is the most common tool to quantify post-stroke disability in everyday practice and by certified raters in clinical trials. However, interobserver variability may affect reliability of retrospective observational studies, including clinical registries. Our aim was to assess real-life consistency between neurologists and physical and rehabilitation medicine physicians using mRS to rate post-stroke disability of patients transferred directly from stroke unit (SU) to rehabilitation ward (RW). Methods This is a retrospective analysis of 132 consecutive acute stroke patients transferred from single tertiary SU to RW located in the same hospital in Poland. Patients were assessed by one rater from each department at the day of transfer. We distinguished between physicians previously certified in using mRS for clinical trials and not-certified physicians using mRS in everyday practice. Results mRS at discharge from SU and on admission to RW was recorded for 105 of 132 patients. The overall agreement was 70.5% (kappa 0.55). Similar agreement was observed in the subset of 30 patients rated by certified physicians in both departments (70.0%, kappa 0.57) and in the subset of 61 patients rated by a pair of certified neurologist and not-certified rehabilitation physician (73.8%, kappa 0.58). Conclusions Everyday consistency between raters from SU and RW in using mRS is modest as in previous validation studies. However, it may be considered sufficient for the purpose of observational studies or stroke registries. It emphasizes the need for easily accessible training in conventional mRS or implementation of specialized tools with predefined questions.
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Affiliation(s)
- Natalia Pożarowszczyk
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego, Warsaw, Poland
| | | | - Iwona Sarzyńska-Długosz
- Neurological Rehabilitation Ward, Institute of Psychiatry and Neurology, Sobieskiego, Warsaw, Poland
| | - Maciej Nowak
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego, Warsaw, Poland
| | - Michał Karliński
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego, Warsaw, Poland
- *Correspondence: Michał Karliński
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10
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Ping Z, Min L, Qiuyun L, Xu C, Qingke B. Prognostic nomogram for the outcomes in acute stroke patients with intravenous thrombolysis. Front Neurosci 2022; 16:1017883. [PMID: 36340757 PMCID: PMC9627298 DOI: 10.3389/fnins.2022.1017883] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background and purpose The prediction of neurological outcomes in ischemic stroke patients is very useful in treatment choices, as well as in post-stroke management. This study is to develop a convenient nomogram for the bedside evaluation of stroke patients with intravenous thrombolysis. Materials and methods We reviewed all enrolled stroke patients with intravenous thrombolysis retrospectively. Favorable outcome was defined as modified Rankin Score (mRs) less than 2 at 90 days post thrombolysis. We compared the clinical characteristics between patients with favorable outcome and poor outcome. Then, we applied logistic regression models and compared their predictability. Results A total of 918 patients were enrolled in this study, 448 patients from one hospital were included to develop a nomogram, whereas 470 patients from the other hospital were used for the external validation. Associated risk factors were identified by multivariate logistic regression. The nomogram was validated by the area under the receiver operating characteristic curve (AUC). A nomogram was developed with baseline NIHSS, blood sugar, blood cholesterol level, part-and full anterior circulation infarction (OCSP type). The AUC was 0.767 (95% CI 0.653–0.772) and 0.836 (95% CI 0.697–0.847) in the derivation and external validation cohorts, respectively. The calibration plot for the probability of severe neurological outcome showed an optimal agreement between the prediction by nomogram and actual observation in both derivation and validation cohorts. Conclusion A convenient outcome evaluation nomogram for patients with intravenous thrombolysis was developed, which could be used by physicians in making clinical decisions and predicting patients’ prognosis.
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Affiliation(s)
- Zheng Ping
- Key Laboratory and Neurosurgery, Shanghai Pudong New Area People’s Hospital, Shanghai, China
- *Correspondence: Zheng Ping, ; orcid.org/0000-0002-3928-3875
| | - Li Min
- Department of Neurology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
| | - Lu Qiuyun
- Department of Neurology, Shanghai Eighth People’s Hospital, Shanghai, China
| | - Chen Xu
- Department of Neurology, Shanghai Eighth People’s Hospital, Shanghai, China
| | - Bai Qingke
- Department of Neurology, Shanghai Pudong New Area People’s Hospital, Shanghai, China
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11
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Fan F, Fu Y, Liu J, Yang X, Zhang H, Li T, Shi H, Wan J, Zhao Y, Wang Y, Feng W, Song D, Wang Y, Mao G, Maimaitili A, Guan S. Multiple Pipeline Embolization Devices for the Treatment of Complex Intracranial Aneurysm: A Multi-Center Study. Front Aging Neurosci 2022; 14:905224. [PMID: 35769602 PMCID: PMC9234332 DOI: 10.3389/fnagi.2022.905224] [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: 03/26/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial primarily demonstrated the safety and efficacy of the implantation of multiple pipeline embolization devices (multi-PEDs) for large/giant intracranial aneurysms. However, no study has focused on when, why, or how to apply multi-PEDs. Objective The purpose of this study was to investigate the indications and strategies of using multi-PEDs for complex intracranial aneurysms. Methods Patients who had been treated with two or more PEDs were included in the post-market multicenter registry study from 2014 to 2019, across 14 centers in China. Indications, strategies, perioperative safety, and clinical outcomes were retrospectively analyzed. The modified Rankin scale (mRS) score was used to evaluate clinical outcomes comprehensively, and the O’Kelly–Marotta (OKM) grading scale was used to evaluate aneurysm healing results. Results A total of 55 intracranial aneurysms were treated with multi-PEDs. There were 20 fusiform aneurysms with a large range, 25 large/giant saccular aneurysms, six aneurysms with failed treatment, and four aneurysms with greatly varied diameters of the parent artery. The strategies included telescope techniques in 40 patients and overlap techniques in 15 patients. In total, 120 stents were deployed in 55 patients. The operation styles included 25 patients (55.6%) with two PEDs, 21 patients (38.2%) with two PEDs combined with coiling, four patients (7.3%) with three PEDs, four patients (7.3%) with three PEDs combined with coiling, and one patient (1.8%) with four PEDs. Angiography revealed OKM D in two, OKM C in seven, and OKM A and B in 46 cases after surgery. During the perioperative period, eight patients developed neurological dysfunction, three of whom died. A total of thirty-four patients were followed up with digital subtraction angiography for 2–45 (8.2 ± 8.0) months. Angiography revealed OKM D in 26, OKM C in five, and OKM B in three. At the last follow-up, the mRS score was 0–1 in 52 patients. Conclusion The treatment of anterior circulation aneurysms with multi-PEDs is safe and effective. The implantation of multi-PEDs could be considered for large-scale fusiform aneurysms, large/giant saccular aneurysms with a jet-sign, salvage of failed PED treatments, and in cases where the diameter of the parent artery varies greatly.
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Affiliation(s)
- Feng Fan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu Fu
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jieqing Wan
- Renji Hospital, School of Medical, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Sheng Guan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Sheng Guan,
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12
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Schreuder FHBM, Scholte M, Ulehake MJ, Sondag L, Rovers MM, Dammers R, Klijn CJM, Grutters JPC. Identifying the Conditions for Cost-Effective Minimally Invasive Neurosurgery in Spontaneous Supratentorial Intracerebral Hemorrhage. Front Neurol 2022; 13:830614. [PMID: 35720058 PMCID: PMC9200972 DOI: 10.3389/fneur.2022.830614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn patients with spontaneous supratentorial intracerebral hemorrhage (ICH), open craniotomy has failed to improve a functional outcome. Innovative minimally invasive neurosurgery (MIS) may improve a health outcome and reduce healthcare costs.AimsBefore starting phase-III trials, we aim to assess conditions that need to be met to reach the potential cost-effectiveness of MIS compared to usual care in patients with spontaneous supratentorial ICH.MethodsWe used a state-transition model to determine at what effectiveness and cost MIS would become cost-effective compared to usual care in terms of quality-adjusted life-years (QALYs) and direct healthcare costs. Threshold and two-way sensitivity analyses were used to determine the minimal effectiveness and maximal costs of MIS, and the most cost-effective strategy for each combination of cost and effectiveness. Scenario and probabilistic sensitivity analyses addressed model uncertainty.ResultsGiven €10,000 of surgical costs, MIS would become cost-effective when at least 0.7–1.3% of patients improve to a modified Rankin Scale (mRS) score of 0–3 compared to usual care. When 11% of patients improve to mRS 0–3, surgical costs may be up to €83,301–€164,382, depending on the population studied. The cost-effectiveness of MIS was mainly determined by its effectiveness. In lower mRS states, MIS needs to be more effective to be cost-effective compared to higher mRS states.ConclusionMIS has the potential to be cost-effective in patients with spontaneous supratentorial ICH, even with relatively low effectiveness. These results support phase-III trials to investigate the effectiveness of MIS.
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Affiliation(s)
- Floris H. B. M. Schreuder
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Floris H. B. M. Schreuder
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marike J. Ulehake
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Sondag
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska M. Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, Netherlands
| | - Catharina J. M. Klijn
- Department of Neurology, Center for Neuroscience, Donders Institute of Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Janneke P. C. Grutters
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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13
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Pinter D, Fandler-Höfler S, Fruhwirth V, Berger L, Bachmaier G, Horner S, Eppinger S, Kneihsl M, Enzinger C, Gattringer T. Relevance of Cognition and Emotion for Patient-Reported Quality of Life After Stroke in Working Age: An Observational Cohort Study. Front Neurol 2022; 13:869550. [PMID: 35547373 PMCID: PMC9081872 DOI: 10.3389/fneur.2022.869550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patient-reported quality of life (QoL) may help to capture sequela of stroke more comprehensively. We aimed to investigate QoL in working age persons with ischemic stroke regarding impaired domains and identify factors associated with better QoL. Methods We invited persons with stroke aged 18–55 years to participate in this prospective observational study. We assessed QoL and self-rated health using the EuroQol 5 Dimension questionnaire (EQ-5D) during hospital stay (baseline) and at 3-months follow-up (FU). Additionally, the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), cognition (Montreal Cognitive assessment, MOCA), emotion (Hospital Anxiety and Depression Scale), and return to work were evaluated. We used hierarchical regression to identify predictors of QoL (self-rated health and QoL Index score) at FU. Results We included 138 persons with stroke (mean age = 43.6 ± 10 years; 41% female; median admission NIHSS = 2), of whom 99 participated at FU. QoL Index and self-rated health were correlated with NIHSS, mRS, anxiety, and depression at both timepoints. Although 80% had favorable functional outcome at FU (mRS < 2), high proportions of these persons reported problems in the “Pain and/or Discomfort” (25.3%) and “Anxiety/Depression” (22.8%) dimensions. Only discharge NIHSS and baseline MOCA independently predicted self-rated health at FU. Female sex, higher discharge NIHSS, and higher baseline depression scores predicted worse QoL Index scores at FU. Conclusions Three months post-stroke, working age persons with stroke frequently reported problems in dimensions not assessed by the routinely used mRS. Despite correlations between clinical scales and QoL, patient-reported outcomes and screening for cognition and emotion ensure a more comprehensive assessment of post-stroke consequences relevant for QoL.
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Affiliation(s)
- Daniela Pinter
- Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.,Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Viktoria Fruhwirth
- Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.,Department of Neurology, Medical University of Graz, Graz, Austria
| | - Lisa Berger
- Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.,Department of Neurology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Susanna Horner
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.,Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Vascular and Interventional Radiology, Medical University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Vascular and Interventional Radiology, Medical University of Graz, Graz, Austria
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14
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Flexman AM, Tung A. In search of the perfect outcome in neuroanaesthesia and neurocritical care. Anaesthesia 2022; 77 Suppl 1:3-7. [DOI: 10.1111/anae.15637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 12/12/2022]
Affiliation(s)
- A. M. Flexman
- Department of Anaesthesiology, Pharmacology and Therapeutics University of British Columbia Vancouver BC Canada
- Department of Anaesthesiology Providence Health Care/St. Paul’s Hospital Vancouver BC Canada
| | - A. Tung
- Department of Anaesthesiology University of Michigan Ann Arbor MI USA
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15
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Abstract
Reperfusion therapy with intravenous alteplase and endovascular therapy are effective treatments for selected patients with acute ischemic stroke. Guidelines for treatment are based upon randomized trials demonstrating substantial treatment effects for highly selected patients based on time from stroke onset and imaging features. However, patients beyond the current established guidelines might benefit with lesser but still clinically significant treatment effects. The STAIR (Stroke Treatment Academic Industry Roundtable) XI meeting convened a workgroup to consider the "outer limits" of reperfusion therapy by defining the current boundaries, and exploring optimal parameters and methodology for determining the outer limits. In addition to statistical significance, the minimum clinically important difference should be considered in exploring the limits of reperfusion therapy. Societal factors and quality of life considerations should be incorporated into assessment of treatment efficacy. The threshold for perception of benefit in the medical community may differ from that necessary for the Food and Drug Administration approval. Data from alternative sources such as platform trials, registries and large pragmatic trials should supplement randomized controlled trials to improve generalizability to routine clinical practice. Further interactions between industry and academic centers should be encouraged.
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Affiliation(s)
- Lawrence R Wechsler
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (L.R.W.)
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ (A.P.J.)
| | - Tudor G Jovin
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ (T.G.J.)
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16
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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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