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Self WH, Shotwell MS, Gibbs KW, de Wit M, Files DC, Harkins M, Hudock KM, Merck LH, Moskowitz A, Apodaca KD, Barksdale A, Safdar B, Javaheri A, Sturek JM, Schrager H, Iovine N, Tiffany B, Douglas IS, Levitt J, Busse LW, Ginde AA, Brown SM, Hager DN, Boyle K, Duggal A, Khan A, Lanspa M, Chen P, Puskarich M, Vonderhaar D, Venkateshaiah L, Gentile N, Rosenberg Y, Troendle J, Bistran-Hall AJ, DeClercq J, Lavieri R, Joly MM, Orr M, Pulley J, Rice TW, Schildcrout JS, Semler MW, Wang L, Bernard GR, Collins SP. Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials. JAMA 2023; 329:1170-1182. [PMID: 37039791 PMCID: PMC10091180 DOI: 10.1001/jama.2023.3546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
Importance Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology. Objective To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II. Design, Setting, and Participants Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022. Interventions A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo. Main Outcomes and Measures The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension. Results Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo. Conclusions and Relevance In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04924660.
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Affiliation(s)
- Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - D. Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michelle Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque
| | | | - Lisa H. Merck
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Aaron Barksdale
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ali Javaheri
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Nicole Iovine
- Department of Medicine, University of Florida, Gainesville
| | | | - Ivor S. Douglas
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph Levitt
- Department of Medicine, Stanford University, Stanford, California
| | | | - Adit A. Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora
| | - Samuel M. Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - David N. Hager
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Akram Khan
- Department of Medicine, Oregon Health & Science University, Portland
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Derek Vonderhaar
- Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - James Troendle
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Amanda J. Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Orr
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew W. Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
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Self WH, Wheeler AP, Stewart TG, Schrager H, Mallada J, Thomas CB, Cataldo VD, O'Neal HR, Shapiro NI, Higgins C, Ginde AA, Chauhan L, Johnson NJ, Henning DJ, Jaiswal SJ, Mammen MJ, Harris ES, Pannu SR, Laguio-Vila M, El Atrouni W, de Wit M, Hoda D, Cohn CS, McWilliams C, Shanholtz C, Jones AE, Raval JS, Mucha S, Ipe TS, Qiao X, Schrantz SJ, Shenoy A, Fremont RD, Brady EJ, Carnahan RH, Chappell JD, Crowe JE, Denison MR, Gilchuk P, Stevens LJ, Sutton RE, Thomsen I, Yoder SM, Bistran-Hall AJ, Casey JD, Lindsell CJ, Wang L, Pulley JM, Rhoads JP, Bernard GR, Rice TW. Neutralizing COVID-19 Convalescent Plasma in Adults Hospitalized With COVID-19: A Blinded, Randomized, Placebo-Controlled Trial. Chest 2022; 162:982-994. [PMID: 35780813 PMCID: PMC9247217 DOI: 10.1016/j.chest.2022.06.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/21/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Convalescent plasma has been one of the most common treatments for COVID-19, but most clinical trial data to date have not supported its efficacy. RESEARCH QUESTION Is rigorously selected COVID-19 convalescent plasma with neutralizing anti-SARS-CoV-2 antibodies an efficacious treatment for adults hospitalized with COVID-19? STUDY DESIGN AND METHODS This was a multicenter, blinded, placebo-controlled randomized clinical trial among adults hospitalized with SARS-CoV-2 infection and acute respiratory symptoms for < 14 days. Enrolled patients were randomly assigned to receive one unit of COVID-19 convalescent plasma (n = 487) or placebo (n = 473). The primary outcome was clinical status (disease severity) 14 days following study infusion measured with a seven-category ordinal scale ranging from discharged from the hospital with resumption of normal activities (lowest score) to death (highest score). The primary outcome was analyzed with a multivariable ordinal regression model, with an adjusted odds ratio (aOR) < 1.0 indicating more favorable outcomes with convalescent plasma than with placebo. In secondary analyses, trial participants were stratified according to the presence of endogenous anti-SARS-CoV-2 antibodies ("serostatus") at randomization. The trial included 13 secondary efficacy outcomes, including 28-day mortality. RESULTS Among 974 randomized patients, 960 were included in the primary analysis. Clinical status on the ordinal outcome scale at 14 days did not differ between the convalescent plasma and placebo groups in the overall population (aOR, 1.04; one-seventh support interval [1/7 SI], 0.82-1.33), in patients without endogenous antibodies (aOR, 1.15; 1/7 SI, 0.74-1.80), or in patients with endogenous antibodies (aOR, 0.96; 1/7 SI, 0.72-1.30). None of the 13 secondary efficacy outcomes were different between groups. At 28 days, 89 of 482 (18.5%) patients in the convalescent plasma group and 80 of 465 (17.2%) patients in the placebo group had died (aOR, 1.04; 1/7 SI, 0.69-1.58). INTERPRETATION Among adults hospitalized with COVID-19, including those seronegative for anti-SARS-CoV-2 antibodies, treatment with convalescent plasma did not improve clinical outcomes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04362176; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research and Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
| | - Allison P Wheeler
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, MA
| | - Jason Mallada
- Department of Pharmacy, Newton-Wellesley Hospital, Massachusetts College of Pharmacy and Health Sciences, Newton, MA
| | - Christopher B Thomas
- Division of Pulmonary and Critical Care, Louisiana State University Health-Sciences Center, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Vince D Cataldo
- Division of Hematology and Oncology, Louisiana State University Health-Sciences Center, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Hollis R O'Neal
- Division of Pulmonary and Critical Care, Louisiana State University Health-Sciences Center, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Conor Higgins
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Lakshmi Chauhan
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Stuti J Jaiswal
- Division of Hospital Medicine, Scripps Clinic, Scripps Research Translational Institute, The Scripps Research Institute, La Jolla, CA
| | - Manoj J Mammen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Estelle S Harris
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Sonal R Pannu
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, OH
| | - Maryrose Laguio-Vila
- Department of Internal Medicine, Division of Infectious Disease, Rochester General Hospital, Rochester, NY
| | - Wissam El Atrouni
- Division of Infectious Diseases, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Marjolein de Wit
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Daanish Hoda
- Oncology Clinical Program, Intermountain Healthcare, Murray, UT
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Carla McWilliams
- Department of Infectious Disease, Cleveland Clinic Florida Weston, Weston, FL
| | - Carl Shanholtz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Jay S Raval
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Simon Mucha
- Department of Critical Care, Respiratory Institute, Cleveland Clinical Health System, Cleveland, OH
| | - Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Xian Qiao
- Sentara Pulmonary, Critical Care, and Sleep Specialists, Sentara Health, Sentara Norfolk General Hospital, Eastern Virginia Medical School, Norfolk, VA
| | | | - Aarthi Shenoy
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Eric J Brady
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN
| | - Robert H Carnahan
- Department of Pediatrics, Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN; Department of Radiology, Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN
| | - James D Chappell
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - James E Crowe
- Department of Pediatrics, Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics, and Department of Pathology, Microbiology, and Immunology, Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN
| | - Mark R Denison
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Pavlo Gilchuk
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN
| | - Laura J Stevens
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Rachel E Sutton
- Immunology and Molecular Pathogeneisis Program, Emory University, Atlanta, GA
| | - Isaac Thomsen
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Sandra M Yoder
- Vanderbilt Vaccine Center, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda J Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research and Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Vanderbilt Institute for Clinical and Translational Research and Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Self WH, Stewart TG, Wheeler AP, El Atrouni W, Bistran-Hall AJ, Casey JD, Cataldo VD, Chappell JD, Cohn CS, Collins JB, Denison MR, de Wit M, Dixon SL, Duggal A, Edwards TL, Fontaine MJ, Ginde AA, Harkins MS, Harrington T, Harris ES, Hoda D, Ipe TS, Jaiswal SJ, Johnson NJ, Jones AE, Laguio-Vila M, Lindsell CJ, Mallada J, Mammen MJ, Metcalf RA, Middleton EA, Mucha S, O'Neal HR, Pannu SR, Pulley JM, Qiao X, Raval JS, Rhoads JP, Schrager H, Shanholtz C, Shapiro NI, Schrantz SJ, Thomsen I, Vermillion KK, Bernard GR, Rice TW. Passive Immunity Trial for Our Nation (PassITON): study protocol for a randomized placebo-control clinical trial evaluating COVID-19 convalescent plasma in hospitalized adults. Trials 2021; 22:221. [PMID: 33743799 PMCID: PMC7980732 DOI: 10.1186/s13063-021-05171-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Convalescent plasma is being used widely as a treatment for coronavirus disease 2019 (COVID-19). However, the clinical efficacy of COVID-19 convalescent plasma is unclear. METHODS The Passive Immunity Trial for Our Nation (PassITON) is a multicenter, placebo-controlled, blinded, randomized clinical trial being conducted in the USA to provide high-quality evidence on the efficacy of COVID-19 convalescent plasma as a treatment for adults hospitalized with symptomatic disease. Adults hospitalized with COVID-19 with respiratory symptoms for less than 14 days are eligible. Enrolled patients are randomized in a 1:1 ratio to 1 unit (200-399 mL) of COVID-19 convalescent plasma that has demonstrated neutralizing function using a SARS-CoV-2 chimeric virus neutralization assay. Study treatments are administered in a blinded fashion and patients are followed for 28 days. The primary outcome is clinical status 14 days after study treatment as measured on a 7-category ordinal scale assessing mortality, respiratory support, and return to normal activities of daily living. Key secondary outcomes include mortality and oxygen-free days. The trial is projected to enroll 1000 patients and is designed to detect an odds ratio ≤ 0.73 for the primary outcome. DISCUSSION This trial will provide the most robust data available to date on the efficacy of COVID-19 convalescent plasma for the treatment of adults hospitalized with acute moderate to severe COVID-19. These data will be useful to guide the treatment of COVID-19 patients in the current pandemic and for informing decisions about whether developing a standardized infrastructure for collecting and disseminating convalescent plasma to prepare for future viral pandemics is indicated. TRIAL REGISTRATION ClinicalTrials.gov NCT04362176 . Registered on 24 April 2020.
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Affiliation(s)
- Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA.
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Allison P Wheeler
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - Wissam El Atrouni
- Division of Infectious Diseases, Department of Internal Medicine, The University of Kansas School of Medicine, Kasas, USA
| | - Amanda J Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Vince D Cataldo
- Division of Hematology and Oncology, Louisiana State University Health-Sciences Center, New Orleans, USA
| | - James D Chappell
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Jessica B Collins
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Mark R Denison
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Marjolein de Wit
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, USA
| | - Sheri L Dixon
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinical Healthcare System, Cleveland, USA
| | - Terri L Edwards
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Magali J Fontaine
- Division of Transfusion Services, Department of Pathology, University of Maryland School of Medicine, Baltimore, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Boulder, USA
| | - Michelle S Harkins
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Thelma Harrington
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, College Park, USA
| | - Estelle S Harris
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, USA
| | | | - Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Fayetteville, USA
| | - Stuti J Jaiswal
- Division of Hospital Medicine, Scripps Clinic, Scripps Research Translational Institute, The Scripps Research Institute, San Diego, USA
| | - Nicholas J Johnson
- Department of Emergency and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Oxford, USA
| | - Maryrose Laguio-Vila
- Department of Internal Medicine, Division of Infectious Disease, Rochester General Hospital, Rochester, USA
| | | | - Jason Mallada
- Department of Pharmacy, Newton-Wellesley Hospital, Massachusetts College of Pharmacy and Health Sciences, Boston, USA
| | - Manoj J Mammen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, State University of New York at Buffalo, Buffalo, USA
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City, USA
| | - Elizabeth A Middleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, USA
| | - Simon Mucha
- Department of Critical Care, Respiratory Institute, Cleveland Clinical Healthcare System, Cleveland, USA
| | - Hollis R O'Neal
- Division of Pulmonary and Critical Care, Louisiana State University Health-Sciences Center, New Orleans, USA
| | - Sonal R Pannu
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University, Columbus, USA
| | - Jill M Pulley
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Xian Qiao
- Sentara Pulmonary, Critical Care, and Sleep Specialists, Sentara Health, Eastern Virginia Medical School, Norfolk, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Harry Schrager
- Newton-Wellesley Hospital, Department of Medicine, Tufts School of Medicine, Boston, USA
| | - Carl Shanholtz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, College Park, USA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Isaac Thomsen
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, USA
| | - Krista K Vermillion
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Todd W Rice
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, 1313 21st Ave South, 312 Oxford House, Nashville, TN, 37232, USA
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
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Self WH, Stewart TG, Wheeler AP, El Atrouni W, Bistran-Hall AJ, Casey JD, Cataldo VD, Chappell JD, Cohn CS, Collins JB, Denison MR, de Wit M, Dixon SL, Duggal A, Edwards TL, Fontaine MJ, Ginde AA, Harkins MS, Harrington T, Harris ES, Hoda D, Ipe TS, Jaiswal SJ, Johnson NJ, Jones AE, Laguio-Vila M, Lindsell CJ, Mallada J, Mammen MJ, Metcalf RA, Middleton EA, Mucha S, O'Neal HR, Pannu SR, Pulley JM, Qiao X, Raval JS, Rhoads JP, Schrager H, Shanholtz C, Shapiro NI, Schrantz SJ, Thomsen I, Vermillion KK, Bernard GR, Rice TW. Passive Immunity Trial for Our Nation (PassITON): study protocol for a randomized placebo-control clinical trial evaluating COVID-19 convalescent plasma in hospitalized adults. Res Sq 2021:rs.3.rs-227796. [PMID: 33688640 PMCID: PMC7941637 DOI: 10.21203/rs.3.rs-227796/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Background: Convalescent plasma is being used widely as a treatment for coronavirus disease 2019 (COVID-19). However, the clinical efficacy of COVID-19 convalescent plasma is unclear. Methods: The Pass ive I mmunity T rial for O ur N ation (PassITON), is a multicenter, placebo-controlled, blinded, randomized clinical trial being conducted in the United States to provide high-quality evidence on the efficacy of COVID-19 convalescent plasma as a treatment for adults hospitalized with symptomatic disease. Adults hospitalized with COVID-19 with respiratory symptoms for less than 14 days are eligible. Enrolled patients are randomized in a 1:1 ratio to 1 unit (200-399 mL) of COVID-19 convalescent plasma that has demonstrated neutralizing function using a SARS-CoV-2 chimeric virus neutralization assay. Study treatments are administered in a blinded fashion and patients are followed for 28 days. The primary outcome is clinical status 14 days after study treatment as measured on a 7-category ordinal scale assessing mortality, respiratory support, and return to normal activities of daily living. Key secondary outcomes include mortality and oxygen-free days. The trial is projected to enroll 1000 patients and is designed to detect an odds ratio ≤ 0.73 for the primary outcome. Discussion: This trial will provide the most robust data available to date on the efficacy of COVID-19 convalescent plasma for the treatment of adults hospitalized with acute moderate to severe COVID-19. These data will be useful to guide the treatment of COVID-19 patients in the current pandemic and for informing decisions about whether developing a standardized infrastructure for collecting and disseminating convalescent plasma to prepare for future viral pandemics is indicated. Trial Registration: ClinicalTrials.gov: NCT04362176. Date of trial registration: April 24, 2020, https://clinicaltrials.gov/ct2/show/NCT04362176.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adit A Ginde
- University of Colorado Denver School of Medicine
| | | | | | | | | | - Tina S Ipe
- University of Arkansas for Medical Sciences
| | | | | | | | | | | | | | - Manoj J Mammen
- State University of New York at Buffalo: University at Buffalo
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Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ, Gandhi D, Mould WA, Ullman N, Ali H, Carhuapoma JR, Kase CS, Lees KR, Dawson J, Wilson A, Betz JF, Sugar EA, Hao Y, Avadhani R, Caron JL, Harrigan MR, Carlson AP, Bulters D, LeDoux D, Huang J, Cobb C, Gupta G, Kitagawa R, Chicoine MR, Patel H, Dodd R, Camarata PJ, Wolfe S, Stadnik A, Money PL, Mitchell P, Sarabia R, Harnof S, Barzo P, Unterberg A, Teitelbaum JS, Wang W, Anderson CS, Mendelow AD, Gregson B, Janis S, Vespa P, Ziai W, Zuccarello M, Awad IA. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019; 393:1021-1032. [PMID: 30739747 PMCID: PMC6894906 DOI: 10.1016/s0140-6736(19)30195-3] [Citation(s) in RCA: 447] [Impact Index Per Article: 89.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. METHODS MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. FINDINGS Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). INTERPRETATION For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. FUNDING National Institute of Neurological Disorders and Stroke and Genentech.
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Affiliation(s)
- Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA.
| | - Richard E Thompson
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Rosenblum
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - W Andrew Mould
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hasan Ali
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alastair Wilson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Joshua F Betz
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Department of Biostatistics, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Yi Hao
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David LeDoux
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Judy Huang
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cully Cobb
- Mercy Neurological Institute Stroke Center, Sacramento, California, USA
| | - Gaurav Gupta
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ryan Kitagawa
- University of Texas, McGovern Medical Center, Houston, TX, USA
| | | | | | - Robert Dodd
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Stacey Wolfe
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | | | | | | | - Pal Barzo
- University of Szeged, Szeged, Hungary
| | | | - Jeanne S Teitelbaum
- Montreal Neurological Institute and Hospital at McGill University, Montreal, QC, Canada
| | - Weimin Wang
- Guangzhou Neuroscience Institute, Guangzhou Liuhua Qiao Hospital, Guangzhou, China
| | - Craig S Anderson
- The George Institute for Global Health China at Peking University Health Science Center, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Scott Janis
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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Fam MD, Hanley D, Stadnik A, Zeineddine HA, Girard R, Jesselson M, Cao Y, Money L, McBee N, Bistran-Hall AJ, Mould WA, Lane K, Camarata PJ, Zuccarello M, Awad IA. Surgical Performance in Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III Clinical Trial. Neurosurgery 2018; 81:860-866. [PMID: 28402516 DOI: 10.1093/neuros/nyx123] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/17/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Minimally invasive thrombolytic evacuation of intracerebral hematoma is being investigated in the ongoing phase III clinical trial of Minimally Invasive Surgery plus recombinant Tissue plasminogen activator for Intracerebral hemorrhage Evacuation (MISTIE III). OBJECTIVE To assess the accuracy of catheter placement and efficacy of hematoma evacuation in relation to surgical approach and surgeon experience. METHODS We performed a trial midpoint interim assessment of 123 cases that underwent the surgical procedure. Accuracy of catheter placement was prospectively assessed by the trial Surgical Center based on prearticulated criteria. Hematoma evacuation efficacy was evaluated based on absolute volume reduction, percentage hematoma evacuation, and reaching the target end-of-treatment volume of <15 mL. One of 3 surgical trajectories was used: anterior (A), posterior (B), and lobar (C). Surgeons were classified based on experience with the MISTIE procedure as prequalified, qualified with probation, and fully qualified. RESULTS The average hematoma volume was 49.7 mL (range 20.0-124), and the mean evacuation rate was 71% (range 18.4%-99.8%). First placed catheters were 58% in good position, 28% suboptimal (but suitable to dose), and 14% poor (requiring repositioning). Posterior trajectory (B) was associated with significantly higher rates of poor placement (35%, P = .01). There was no significant difference in catheter placement accuracy among surgeons of varying experience. Hematoma evacuation efficacy was not significantly different among the 3 surgical approaches or different surgeons' experience. CONCLUSION Ongoing surgical education and quality monitoring in MISTIE III have resulted in consistent rates of hematoma evacuation despite technical challenges with the surgical approaches and among surgeons of varying experience.
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Affiliation(s)
- Maged D Fam
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Agnieszka Stadnik
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Hussein A Zeineddine
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Romuald Girard
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Michael Jesselson
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Ying Cao
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Lynn Money
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Amanda J Bistran-Hall
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas; Investigators of the MISTIE III Trial
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Issam A Awad
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
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7
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Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013; 44:627-34. [PMID: 23391763 PMCID: PMC4124642 DOI: 10.1161/strokeaha.111.000411] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it. METHODS Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans. RESULTS Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm(3) for the surgical cohort and 40.7±13.9 cm(3) for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm(3) than medical cohort: 41.7±14.6 cm(3) (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (ρ=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm(3); and surgical aspiration only, 24.5±14.0 cm(3) (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm(3) and 24.4±8.6 cm(3) in surgical aspiration only (P=0.41). CONCLUSIONS Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.
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Affiliation(s)
- W. Andrew Mould
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - J. Ricardo Carhuapoma
- Departments of Neurology, Neurosurgery and Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - John Muschelli
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Karen Lane
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Timothy C Morgan
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Nichol A McBee
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Amanda J Bistran-Hall
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Natalie L Ullman
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Paul Vespa
- Departments of Neurology and Neurosurgery, UCLA School of Medicine, Los Angeles, CA
| | - Neil A Martin
- Departments of Neurology and Neurosurgery, UCLA School of Medicine, Los Angeles, CA
| | - Issam Awad
- Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
| | - Daniel F. Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD
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