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Isakadze N, Kim CH, Marvel FA, Ding J, MacFarlane Z, Gao Y, Spaulding EM, Stewart KJ, Nimbalkar M, Bush A, Broderick A, Gallagher J, Molello N, Commodore‐Mensah Y, Michos ED, Dunn P, Hanley DF, McBee N, Martin SS, Mathews L. Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health. J Am Heart Assoc 2024; 13:e030654. [PMID: 38226511 PMCID: PMC10926786 DOI: 10.1161/jaha.123.030654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 12/01/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone. METHODS The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed. CONCLUSIONS The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.
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Affiliation(s)
- Nino Isakadze
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Chang H. Kim
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Francoise A. Marvel
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Jie Ding
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Zane MacFarlane
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Yumin Gao
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Erin M. Spaulding
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
- Johns Hopkins University School of NursingBaltimoreMDUSA
- Welch Center for Prevention, Epidemiology, and Clinical ResearchJohns Hopkins UniversityBaltimoreMDUSA
| | - Kerry J. Stewart
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Mansi Nimbalkar
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Alexandra Bush
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Ashley Broderick
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Jeanmarie Gallagher
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Nancy Molello
- Johns Hopkins Center for Health EquityBaltimoreMDUSA
| | - Yvonne Commodore‐Mensah
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
- Johns Hopkins University School of NursingBaltimoreMDUSA
- Johns Hopkins Center for Health EquityBaltimoreMDUSA
| | - Erin D. Michos
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
| | - Patrick Dunn
- Center for Health Technology and Innovation, American Heart AssociationDallasTXUSA
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Daniel F. Hanley
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Division of Neurosurgery, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMDUSA
- Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Nichol McBee
- Ginsburg Institute for Health Equity, Nemours Children’s HealthOrlandoFLUSA
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Seth S. Martin
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
- Johns Hopkins Center for Health EquityBaltimoreMDUSA
| | - Lena Mathews
- Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Center for Mobile Technologies to Achieve Equity in Cardiovascular Health (mTECH Center)BaltimoreMDUSA
- Johns Hopkins Center for Health EquityBaltimoreMDUSA
- Welch Center for Prevention, Epidemiology, and Clinical ResearchJohns Hopkins UniversityBaltimoreMDUSA
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2
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Rivera-Lara L, Cho SM, Li Y, Ali H, McBee N, Awad IA, Avadhani R, Hanley DF, Gandhi D, Walborn N, Murthy SB, Ziai WC. Mechanistic Evaluation of Diffusion Weighted Hyperintense Lesions After Large Spontaneous Intracerebral Hemorrhage: A Subgroup Analysis of MISTIE III. Neurocrit Care 2023:10.1007/s12028-023-01890-3. [PMID: 38040993 DOI: 10.1007/s12028-023-01890-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Ischemic lesions on diffusion weighted imaging (DWI) are common after acute spontaneous intracerebral hemorrhage (ICH) but are poorly understood for large ICH volumes (> 30 mL). We hypothesized that large blood pressure drops and effect modification by cerebral small vessel disease markers on magnetic resonance imaging (MRI) are associated with DWI lesions. METHODS This was an exploratory analysis of participants in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial with protocolized brain MRI scans within 7 days from ICH. Multivariable logistic regression analysis was performed to assess biologically relevant factors associated with DWI lesions, and relationships between DWI lesions and favorable ICH outcomes (modified Rankin Scale 0-3). RESULTS Of 499 enrolled patients, 300 had MRI at median 7.5 days (interquartile range 7-8), and 178 (59%) had DWI lesions. The incidence of DWI lesions was higher in patients with systolic blood pressure (SBP) reduction ≥ 80 mm Hg in first 24 h (76%). In adjusted models, factors associated with DWI lesions were as follows: admission intraventricular hematoma volume (p = 0.03), decrease in SBP ≥ 80 mm Hg from admission to day 1 (p = 0.03), and moderate-to-severe white matter disease (p = 0.01). Patients with DWI lesions had higher odds of severe disability at 1 month (p = 0.04), 6 months (p = 0.036), and 12 months (p < 0.01). No evidence of effect modification by cerebral small vessel disease on blood pressure was found. CONCLUSIONS In patients with large hypertensive ICH, white matter disease, intraventricular hemorrhage volume, and large reductions in SBP over the first 24 h were independently associated with DWI lesions. Further investigation of potential hemodynamic mechanisms of ischemic injury after large ICH is warranted.
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Affiliation(s)
- Lucia Rivera-Lara
- Division of Stroke and Neurocritical Care, Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology and Neurosurgery, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Yunke Li
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Hasan Ali
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Issam A Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Radhika Avadhani
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Gandhi
- Department of Radiology, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan Walborn
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology and Neurosurgery, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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3
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Palm ME, Edwards TL, Wieber C, Kay MT, Marion E, Boone L, Nanni A, Jones M, Pham E, Hildreth M, Lane K, McBee N, Benjamin DK, Bernard GR, Dean JM, Dwyer JP, Ford DE, Hanley DF, Harris PA, Wilkins CH, Selker HP. Development, implementation, and dissemination of operational innovations across the trial innovation network. J Clin Transl Sci 2023; 7:e251. [PMID: 38229905 PMCID: PMC10790103 DOI: 10.1017/cts.2023.658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 01/18/2024] Open
Abstract
Improving the quality and conduct of multi-center clinical trials is essential to the generation of generalizable knowledge about the safety and efficacy of healthcare treatments. Despite significant effort and expense, many clinical trials are unsuccessful. The National Center for Advancing Translational Science launched the Trial Innovation Network to address critical roadblocks in multi-center trials by leveraging existing infrastructure and developing operational innovations. We provide an overview of the roadblocks that led to opportunities for operational innovation, our work to develop, define, and map innovations across the network, and how we implemented and disseminated mature innovations.
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Affiliation(s)
- Marisha E. Palm
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Terri L. Edwards
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cortney Wieber
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Marie T. Kay
- University of Utah Health, Salt Lake City, UT, USA
| | - Eve Marion
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie Boone
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angeline Nanni
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Jones
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eilene Pham
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Meghan Hildreth
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nichol McBee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jamie P. Dwyer
- University of Utah Health, Salt Lake City, UT, USA
- Utah Clinical and Translational Sciences Institute, Salt Lake City, UT, USA
| | - Daniel E. Ford
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F. Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul A. Harris
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Biostatistics, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Harry P. Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
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4
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Di Stefano L, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Bengtson CD, Gadomski A, Geriak M, Puskarich MA, Salathe MA, Schutte AE, Tignanelli CJ, Victory J, Bierer BE, Hanley DF, Freilich DA. Losartan in hospitalized patients with COVID-19 in North America: An individual participant data meta-analysis. Medicine (Baltimore) 2023; 102:e33904. [PMID: 37335665 PMCID: PMC10256351 DOI: 10.1097/md.0000000000033904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) have been hypothesized to benefit patients with COVID-19 via the inhibition of viral entry and other mechanisms. We conducted an individual participant data (IPD) meta-analysis assessing the effect of starting the ARB losartan in recently hospitalized COVID-19 patients. METHODS We searched ClinicalTrials.gov in January 2021 for U.S./Canada-based trials where an angiotensin-converting enzyme inhibitors/ARB was a treatment arm, targeted outcomes could be extrapolated, and data sharing was allowed. Our primary outcome was a 7-point COVID-19 ordinal score measured 13 to 16 days post-enrollment. We analyzed data by fitting multilevel Bayesian ordinal regression models and standardizing the resulting predictions. RESULTS 325 participants (156 losartan vs 169 control) from 4 studies contributed IPD. Three were randomized trials; one used non-randomized concurrent and historical controls. Baseline covariates were reasonably balanced for the randomized trials. All studies evaluated losartan. We found equivocal evidence of a difference in ordinal scores 13-16 days post-enrollment (model-standardized odds ratio [OR] 1.10, 95% credible interval [CrI] 0.76-1.71; adjusted OR 1.15, 95% CrI 0.15-3.59) and no compelling evidence of treatment effect heterogeneity among prespecified subgroups. Losartan had worse effects for those taking corticosteroids at baseline after adjusting for covariates (ratio of adjusted ORs 0.29, 95% CrI 0.08-0.99). Hypotension serious adverse event rates were numerically higher with losartan. CONCLUSIONS In this IPD meta-analysis of hospitalized COVID-19 patients, we found no convincing evidence for the benefit of losartan versus control treatment, but a higher rate of hypotension adverse events with losartan.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, CO
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Charles D. Bengtson
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Anne Gadomski
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | | | - Michael A. Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthias A. Salathe
- Department of Internal Medicine, University of Kansas Medical Center, KS City, KS
| | - Aletta E. Schutte
- School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Daniel A. Freilich
- Bassett Research Institute, Bassett Medical Center, Cooperstown, NY
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, NY
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5
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Shoham S, Bloch EM, Casadevall A, Hanley D, Lau B, Gebo K, Cachay E, Kassaye SG, Paxton JH, Gerber J, Levine AC, Naeim A, Currier J, Patel B, Allen ES, Anjan S, Appel L, Baksh S, Blair PW, Bowen A, Broderick P, Caputo CA, Cluzet V, Elena MC, Cruser D, Ehrhardt S, Forthal D, Fukuta Y, Gawad AL, Gniadek T, Hammel J, Huaman MA, Jabs DA, Jedlicka A, Karlen N, Klein S, Laeyendecker O, Karen L, McBee N, Meisenberg B, Merlo C, Mosnaim G, Park HS, Pekosz A, Petrini J, Rausch W, Shade DM, Shapiro JR, Singleton RJ, Sutcliffe C, Thomas DL, Yarava A, Zand M, Zenilman JM, Tobian AA, Sullivan DJ. Transfusing Convalescent Plasma as Post-Exposure Prophylaxis Against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection: A Double-Blinded, Phase 2 Randomized, Controlled Trial. Clin Infect Dis 2023; 76:e477-e486. [PMID: 35579509 PMCID: PMC9129191 DOI: 10.1093/cid/ciac372] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The efficacy of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) convalescent plasma (CCP) for preventing infection in exposed, uninfected individuals is unknown. CCP might prevent infection when administered before symptoms or laboratory evidence of infection. METHODS This double-blinded, phase 2 randomized, controlled trial (RCT) compared the efficacy and safety of prophylactic high titer (≥1:320 by Euroimmun ELISA) CCP with standard plasma. Asymptomatic participants aged ≥18 years with close contact exposure to a person with confirmed coronavirus disease 2019 (COVID-19) in the previous 120 hours and negative SARS-CoV-2 test within 24 hours before transfusion were eligible. The primary outcome was new SARS-CoV-2 infection. RESULTS In total, 180 participants were enrolled; 87 were assigned to CCP and 93 to control plasma, and 170 transfused at 19 sites across the United States from June 2020 to March 2021. Two were excluded for screening SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) positivity. Of the remaining 168 participants, 12/81 (14.8%) CCP and 13/87 (14.9%) control recipients developed SARS-CoV-2 infection; 6 (7.4%) CCP and 7 (8%) control recipients developed COVID-19 (infection with symptoms). There were no COVID-19-related hospitalizations in CCP and 2 in control recipients. Efficacy by restricted mean infection free time (RMIFT) by 28 days for all SARS-CoV-2 infections (25.3 vs 25.2 days; P = .49) and COVID-19 (26.3 vs 25.9 days; P = .35) was similar for both groups. CONCLUSIONS Administration of high-titer CCP as post-exposure prophylaxis, although appearing safe, did not prevent SARS-CoV-2 infection. CLINICAL TRIALS REGISTRATION NCT04323800.
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Affiliation(s)
| | | | | | | | - Bryan Lau
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Mosaic Consulting Ltd., Israel
| | | | - Edward Cachay
- Department of Medicine, Division of Infectious Diseases
| | - Seble G. Kassaye
- Division of Infectious Diseases/Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - James H. Paxton
- Department of Emergency Medicine Wayne State University, Detroit, Michigan, USA
| | - Jonathan Gerber
- Department of Medicine, Division of Hematology and Oncology, University of Massachusetts Chan Medical School, Worchester, Massachusetts, USA
| | - Adam C Levine
- Department of Emergency Medicine, Rhode Island Hospital/Brown University, Providence, Rhode Island, USA
| | - Arash Naeim
- Department of Medicine, Division of Infectious Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Judith Currier
- Department of Medicine, Division of Infectious Diseases, University of California, Los Angeles, Los Angeles, California, USA
| | - Bela Patel
- Department of Medicine, Division Critical Care Medicine, University of Texas Health, Houston, Texas, USA
| | - Elizabeth S. Allen
- Department of Pathology, University of California, San Diego, San Diego, California, USA
| | - Shweta Anjan
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Sheriza Baksh
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Mosaic Consulting Ltd., Israel
| | | | | | | | | | - Valerie Cluzet
- Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, New York, USA
| | | | | | - Stephan Ehrhardt
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Mosaic Consulting Ltd., Israel
| | - Donald Forthal
- Department of Medicine, Division of Infectious Diseases, University of California, Irvine, Irvine, California, USA
| | - Yuriko Fukuta
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | | | - Thomas Gniadek
- Department of Pathology, Northshore University Health System, Evanston, Illinois, USA
| | | | - Moises A. Huaman
- Department of Medicine, Division of Infectious Diseases, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas A. Jabs
- Department of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Sabra Klein
- Department of Molecular Microbiology and Immunology
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA
| | | | | | | | | | | | - Han-Sol Park
- Department of Molecular Microbiology and Immunology
| | | | - Joann Petrini
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA
| | - William Rausch
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, USA
| | - David M. Shade
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Mosaic Consulting Ltd., Israel
| | | | | | - Catherine Sutcliffe
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Mosaic Consulting Ltd., Israel
| | | | | | - Martin Zand
- Department of Medicine, University of Rochester, Rochester, New York, USA
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6
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. PLoS One 2022; 17:e0273526. [PMID: 36173983 PMCID: PMC9521809 DOI: 10.1371/journal.pone.0273526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. METHODS We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. RESULTS Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). CONCLUSIONS The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, United States of America
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, United States of America
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, United States of America
- University of Utah, Salt Lake City, Utah, United States of America
| | - Whitney R. Buckel
- Pharmacy Services, Intermountain Healthcare, Murray, Utah, United States of America
| | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
- Vaccine Center, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York, United States of America
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, United States of America
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Shah VA, Thompson RE, Yenokyan G, Acosta JN, Avadhani R, Dlugash R, McBee N, Li Y, Hansen BM, Ullman N, Falcone G, Awad IA, Hanley DF, Ziai WC. One-Year Outcome Trajectories and Factors Associated with Functional Recovery Among Survivors of Intracerebral and Intraventricular Hemorrhage With Initial Severe Disability. JAMA Neurol 2022; 79:856-868. [PMID: 35877105 PMCID: PMC9316056 DOI: 10.1001/jamaneurol.2022.1991] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients who survive severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) typically have poor functional outcome in the short term and understanding of future recovery is limited. Objective To describe 1-year recovery trajectories among ICH and IVH survivors with initial severe disability and assess the association of hospital events with long-term recovery. Design, Setting, and Participants This post hoc analysis pooled all individual patient data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 trial (CLEAR-III) and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE-III) phase 3 trial in multiple centers across the US, Canada, Europe, and Asia. Patients were enrolled from August 1, 2010, to September 30, 2018, with a follow-up duration of 1 year. Of 999 enrolled patients, 724 survived with a day 30 modified Rankin Scale score (mRS) of 4 to 5 after excluding 13 participants with missing day 30 mRS. An additional 9 patients were excluded because of missing 1-year mRS. The final pooled cohort included 715 patients (71.6%) with day 30 mRS 4 to 5. Data were analyzed from July 2019 to January 2022. Exposures CLEAR-III participants randomized to intraventricular alteplase vs placebo. MISTIE-III participants randomized to stereotactic thrombolysis of hematoma vs standard medical care. Main Outcomes and Measures Primary outcome was 1-year mRS. Patients were dichotomized into good outcome at 1 year (mRS 0 to 3) vs poor outcome at 1 year (mRS 4 to 6). Multivariable logistic regression models assessed associations between prospectively adjudicated hospital events and 1-year good outcome after adjusting for demographic characteristics, ICH and IVH severity, and trial cohort. Results Of 715 survivors, 417 (58%) were male, and the overall mean (SD) age was 60.3 (11.7) years. Overall, 174 participants (24.3%) were Black, 491 (68.6%) were White, and 49 (6.9%) were of other races (including Asian, Native American, and Pacific Islander, consolidated owing to small numbers); 98 (13.7%) were of Hispanic ethnicity. By 1 year, 129 participants (18%) had died and 308 (43%) had achieved mRS 0 to 3. In adjusted models for the combined cohort, diabetes (adjusted odds ratio [aOR], 0.50; 95% CI, 0.26-0.96), National Institutes of Health Stroke Scale (aOR, 0.93; 95% CI, 0.90-0.96), severe leukoaraiosis (aOR, 0.30; 95% CI, 0.16-0.54), pineal gland shift (aOR, 0.87; 95% CI, 0.76-0.99]), acute ischemic stroke (aOR, 0.44; 95% CI, 0.21-0.94), gastrostomy (aOR, 0.30; 95% CI, 0.17-0.50), and persistent hydrocephalus by day 30 (aOR, 0.37; 95% CI, 0.14-0.98) were associated with lack of recovery. Resolution of ICH (aOR, 1.82; 95% CI, 1.08-3.04) and IVH (aOR, 2.19; 95% CI, 1.02-4.68) by day 30 were associated with recovery to good outcome. In the CLEAR-III model, cerebral perfusion pressure less than 60 mm Hg (aOR, 0.30; 95% CI, 0.13-0.71), sepsis (aOR, 0.05; 95% CI, 0.00-0.80), and prolonged mechanical ventilation (aOR, 0.96; 95% CI, 0.92-1.00 per day), and in MISTIE-III, need for intracranial pressure monitoring (aOR, 0.35; 95% CI, 0.12-0.98), were additional factors associated with poor outcome. Thirty-day event-based models strongly predicted 1-year outcome (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.83-0.90), with significantly improved discrimination over models using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80; P < .001). Conclusions and Relevance Among survivors of severe ICH and IVH with initial poor functional outcome, more than 40% recovered to good outcome by 1 year. Hospital events were strongly associated with long-term functional recovery and may be potential targets for intervention. Avoiding early pessimistic prognostication and delaying prognostication until after treatment may improve ability to predict future recovery.
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Affiliation(s)
- Vishank A. Shah
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julian N. Acosta
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yunke Li
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The George Institute China at Peking University Health Sciences Center, Beijing, China
| | | | - Natalie Ullman
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Guido Falcone
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, Chicago, Illinois
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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8
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. medRxiv 2022:2022.01.10.22269008. [PMID: 35043124 PMCID: PMC8764733 DOI: 10.1101/2022.01.10.22269008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. Methods We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. Results Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). Conclusions The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
- Current address: FHI 360, Durham, North Carolina
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
- University of Utah, Salt Lake City, Utah
| | | | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
- Vaccine Center, New York University Grossman School of Medicine, New York, New York
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York
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9
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Bloch EM, Tobian AAR, Shoham S, Hanley DF, Gniadek TJ, Cachay ER, Meisenberg BR, Kafka K, Marshall C, Heath SL, Shenoy A, Paxton JH, Levine A, Forthal D, Fukuta Y, Huaman MA, Ziman A, Adamski J, Gerber J, Cruser D, Kassaye SG, Mosnaim GS, Patel B, Metcalf RA, Anjan S, Reisler RB, Yarava A, Lane K, McBee N, Gawad A, Raval JS, Zand M, Abinante M, Broderick PB, Casadevall A, Sullivan D, Gebo KA. How do I implement an outpatient program for the administration of convalescent plasma for COVID-19? Transfusion 2022; 62:933-941. [PMID: 35352362 PMCID: PMC9086144 DOI: 10.1111/trf.16871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 02/03/2022] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 11/30/2022]
Abstract
Convalescent plasma, collected from donors who have recovered from a pathogen of interest, has been used to treat infectious diseases, particularly in times of outbreak, when alternative therapies were unavailable. The COVID-19 pandemic revived interest in the use of convalescent plasma. Large observational studies and clinical trials that were executed during the pandemic provided insight into how to use convalescent plasma, whereby high levels of antibodies against the pathogen of interest and administration early within the time course of the disease are critical for optimal therapeutic effect. Several studies have shown outpatient administration of COVID-19 convalescent plasma (CCP) to be both safe and effective, preventing clinical progression in patients when administered within the first week of COVID-19. The United States Food and Drug Administration expanded its emergency use authorization (EUA) to allow for the administration of CCP in an outpatient setting in December 2021, at least for immunocompromised patients or those on immunosuppressive therapy. Outpatient transfusion of CCP and infusion of monoclonal antibody therapies for a highly transmissible infectious disease introduces nuanced challenges related to infection prevention. Drawing on our experiences with the clinical and research use of CCP, we describe the logistical considerations and workflow spanning procurement of qualified products, infrastructure, staffing, transfusion, and associated management of adverse events. The purpose of this description is to facilitate the efforts of others intent on establishing outpatient transfusion programs for CCP and other antibody-based therapies.
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Affiliation(s)
- Evan M. Bloch
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Aaron A. R. Tobian
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Shmuel Shoham
- Department of Medicine, Division of Infectious DiseasesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Daniel F. Hanley
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Thomas J. Gniadek
- Department of PathologyNorthshore University Health SystemEvanstonIllinoisUSA
| | - Edward R. Cachay
- Department of Medicine, Division of Infectious DiseasesUniversity of CaliforniaSan DiegoCaliforniaUnited States
| | | | - Kimberly Kafka
- Department of PediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Christi Marshall
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Sonya L. Heath
- Department of Medicine, Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Aarthi Shenoy
- Department of Medicine, Division of Hematology and OncologyMedstar Washington Hospital CenterWashingtonDistrict of ColumbiaUSA
| | - James H. Paxton
- Department of Emergency MedicineWayne State UniversityDetroitMichiganUSA
| | - Adam Levine
- Department of Emergency MedicineRhode Island Hospital/Brown UniversityProvidenceRhode IslandUSA
| | - Donald Forthal
- Department of Medicine, Division of Infectious DiseasesUniversity of CaliforniaIrvineCaliforniaUnited States
| | - Yuriko Fukuta
- Department of Medicine, Section of Infectious DiseasesBaylor College of MedicineHoustonTexasUSA
| | - Moises A. Huaman
- Department of Medicine, Division of Infectious DiseasesUniversity of CincinnatiCincinnatiOhioUSA
| | - Alyssa Ziman
- Department of PathologyUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Jill Adamski
- Department of Laboratory MedicineMayo Clinic HospitalPhoenixArizonaUSA
| | - Jonathan Gerber
- Department of Medicine, Division of Hematology and OncologyUniversity of MassachusettsWorchesterMassachusettsUSA
| | - Daniel Cruser
- Nuvance Health Vassar Brothers Medical CenterPoughkeepsieNew YorkUSA
| | - Seble G. Kassaye
- Department of Medicine, Division of Infectious DiseasesMedstar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
| | - Giselle S. Mosnaim
- Division of Allergy and Immunology, Department of MedicineNorthshore University Health SystemEvanstonIllinoisUSA
| | - Bela Patel
- Department of Medicine, Divisions of Pulmonary and Critical Care MedicineUniversity of Texas Health Science CenterHoustonTexasUSA
| | - Ryan A. Metcalf
- Department of Medicine, Division of Infectious DiseasesUniversity of UtahSalt Lake CityUtahUSA
| | - Shweta Anjan
- Department of Medicine, Division of Infectious DiseasesUniversity of Miami, Miller School of MedicineMiamiFloridaUSA
| | | | - Anusha Yarava
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Karen Lane
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nichol McBee
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amy Gawad
- Department of NeurologyBrain Injury Outcomes Division, Johns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jay S. Raval
- Department of PathologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Martin Zand
- Department of MedicineUniversity of RochesterRochesterNew YorkUSA
| | | | | | - Arturo Casadevall
- Departments of Molecular Microbiology and ImmunologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - David Sullivan
- Departments of Molecular Microbiology and ImmunologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Kelly A. Gebo
- Department of Medicine, Division of Infectious DiseasesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Shoham S, Bloch EM, Casadevall A, Hanley D, Lau B, Gebo K, Cachay E, Kassaye SG, Paxton JH, Gerber J, Levine AC, Currier J, Patel B, Allen ES, Anjan S, Appel L, Baksh S, Blair PW, Bowen A, Broderick P, Caputo CA, Cluzet V, Cordisco ME, Cruser D, Ehrhardt S, Forthal D, Fukuta Y, Gawad AL, Gniadek T, Hammel J, Huaman MA, Jabs DA, Jedlicka A, Karlen N, Klein S, Laeyendecker O, Lane K, McBee N, Meisenberg B, Merlo C, Mosnaim G, Park HS, Pekosz A, Petrini J, Rausch W, Shade DM, Shapiro JR, Singleton JR, Sutcliffe C, Thomas DL, Yarava A, Zand M, Zenilman JM, Tobian AA, Sullivan D. Randomized controlled trial transfusing convalescent plasma as post-exposure prophylaxis against SARS-CoV-2 infection. medRxiv 2021:2021.12.13.21267611. [PMID: 34931202 PMCID: PMC8687473 DOI: 10.1101/2021.12.13.21267611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The efficacy of SARS-CoV-2 convalescent plasma (CCP) for preventing infection in exposed, uninfected individuals is unknown. We hypothesized that CCP might prevent infection when administered before symptoms or laboratory evidence of infection. METHODS This double-blinded, phase 2 randomized, controlled trial (RCT) compared the efficacy and safety of prophylactic high titer (≥1:320) CCP with standard plasma. Asymptomatic participants aged ≥18 years with close contact exposure to a person with confirmed COVID-19 in the previous 120 hours and negative SARS-CoV-2 test within 24 hours before transfusion were eligible. The primary outcome was development of SARS-CoV-2 infection. RESULTS 180 participants were enrolled; 87 were assigned to CCP and 93 to control plasma, and 170 transfused at 19 sites across the United States from June 2020 to March 2021. Two were excluded for SARS-CoV-2 RT-PCR positivity at screening. Of the remaining 168 participants, 12/81 (14.8%) CCP and 13/87 (14.9%) control recipients developed SARS-CoV-2 infection; 6 (7.4%) CCP and 7 (8%) control recipients developed COVID-19 (infection with symptoms). There were no COVID-19-related hospitalizations in CCP and 2 in control recipients. There were 28 adverse events in CCP and 58 in control recipients. Efficacy by restricted mean infection free time (RMIFT) by 28 days for all SARS-CoV-2 infections (25.3 vs. 25.2 days; p=0.49) and COVID-19 (26.3 vs. 25.9 days; p=0.35) were similar for both groups. CONCLUSION In this trial, which enrolled persons with recent exposure to a person with confirmed COVID-19, high titer CCP as post-exposure prophylaxis appeared safe, but did not prevent SARS-CoV-2 infection. TRIAL REGISTRATION Clinicaltrial.gov number NCT04323800 .
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Polster SP, Carrión-Penagos J, Lyne SB, Gregson BA, Cao Y, Thompson RE, Stadnik A, Girard R, Money PL, Lane K, McBee N, Ziai W, Mould WA, Iqbal A, Metcalfe S, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Zuccarello M, Mendelow AD, Hanley DF, Awad IA. Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa572_s125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kim H, Flemming KD, Nelson JA, Lui A, Majersik JJ, Cruz MD, Zabramski J, Trevizo O, Lanzino G, Zafar A, Torbey M, Mabray MC, Robinson M, Narvid J, Lupo J, Thompson RE, Hanley DF, McBee N, Treine K, Ostapkovich N, Stadnik A, Piedad K, Hobson N, Carroll T, Shkoukani A, Carrión-Penagos J, Mendoza-Puccini C, Koenig JI, Awad I. Baseline Characteristics of Patients With Cavernous Angiomas With Symptomatic Hemorrhage in Multisite Trial Readiness Project. Stroke 2021; 52:3829-3838. [PMID: 34525838 DOI: 10.1161/strokeaha.120.033487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH. METHODS This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-sample t test was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion. RESULTS As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score <5). However, perceived health problems affecting quality of life were reported in >30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety (P=0.007), but better depression (P=0.002) and social satisfaction scores (P=0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites. CONCLUSIONS These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.
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Affiliation(s)
- Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.).,Department of Epidemiology and Biostatistics, University of California, San Francisco. (H.K.)
| | | | - Jeffrey A Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.)
| | - Avery Lui
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco. (H.K., J.A.N., A.L.)
| | - Jennifer J Majersik
- Department of Neurology, University of Utah, Salt Lake City (J.J.M., M.D.C.)
| | - Michael Dela Cruz
- Department of Neurology, University of Utah, Salt Lake City (J.J.M., M.D.C.)
| | - Joseph Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.Z., O.T.)
| | - Odilette Trevizo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (J.Z., O.T.)
| | | | - Atif Zafar
- Department of Neurology, University of Toronto, Canada (A.Z.)
| | - Michel Torbey
- Department of Neurology, University of New Mexico, Albuquerque. (M.T.)
| | - Marc C Mabray
- Department of Radiology, University of New Mexico, Albuquerque. (M.C.M.)
| | - Myranda Robinson
- Department of Neurosurgery, University of New Mexico, Albuquerque. (M.R.)
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging, University of California, San Francisco. (J.N., J.L.)
| | - Janine Lupo
- Department of Radiology and Biomedical Imaging, University of California, San Francisco. (J.N., J.L.)
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD. (R.E.T.)
| | - Daniel F Hanley
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Nichol McBee
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Kevin Treine
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Noeleen Ostapkovich
- Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD. (D.F.H., N.M., K.T., N.O.)
| | - Agnieszka Stadnik
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Kristina Piedad
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Nicholas Hobson
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Timothy Carroll
- Department of Diagnostic Radiology, University of Chicago, IL. (T.C.)
| | - Abdallah Shkoukani
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Julián Carrión-Penagos
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
| | - Carolina Mendoza-Puccini
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD. (C.M.-P.)
| | - James I Koenig
- Division of Neuroscience, National Institute of Neurological Disorders and Stroke, Bethesda, MD. (J.I.K.)
| | - Issam Awad
- Department of Neurosurgery, University of Chicago, IL. (A. Stadnik, K.P., N.H., A. Shkoukani, J.C.-P., I.A.)
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Avadhani R, Thompson RE, Carhuapoma L, Yenokyan G, McBee N, Lane K, Ostapkovich N, Stadnik A, Awad IA, Hanley DF, Ziai WC. Post-Stroke Depression in Patients with Large Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106082. [PMID: 34517296 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106082] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/30/2021] [Accepted: 08/24/2021] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To determine factors associated with post-stroke depression (PSD) and relationship between PSD and functional outcomes in spontaneous intracerebral hemorrhage (ICH) using prospective data from a large clinical trial. MATERIALS AND METHODS MISTIE III, a randomized, multicenter, placebo-controlled trial, was conducted to determine if minimally invasive surgery with thrombolysis improves outcome compared to standard medical care. Our primary outcome was post-stroke depression at 180 days. Secondary outcomes were change in blinded assessment of modified Rankin Scale (mRS) from 30 to 180 days, and from 180 to 365 days. Logistic regression models were used to assess the relationship between PSD and outcomes. RESULTS Among 379 survivors at day 180, 308 completed Center for Epidemiologic Studies Depression Scale, of which 111 (36%) were depressed. In the multivariable analysis, female sex (Adjusted Odds Ratio [AOR], 95% Confidence Interval [CI]: 1.93 [1.07-3.48]), Hispanic ethnicity (3.05 [1.19-7.85]), intraventricular hemorrhage (1.88 [1.02-3.45]), right-sided lesions (3.00 [1.43-6.29]), impaired mini mental state examination at day 30 (2.50 [1.13-5.54]), and not being at home at day 30 (3.17 [1.05-9.57]) were significantly associated with higher odds of PSD. Patients with PSD were significantly more likely to have unchanged or worsening mRS from day 30 to 180 (42.3% vs. 25.9%; p=0.004), but not from day 180 to 365. CONCLUSIONS We report high burden of PSD in patients with large volume ICH. Impaired cognition and not living at home may be more important than physical limitations in predicting PSD. Increased screening of high-risk post-stroke patients for depression, especially females and Hispanics may be warranted.
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Affiliation(s)
- Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lourdes Carhuapoma
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Noeleen Ostapkovich
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Agnieszka Stadnik
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Issam A Awad
- Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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14
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Polster SP, Carrión-Penagos J, Lyne SB, Gregson BA, Cao Y, Thompson RE, Stadnik A, Girard R, Money PL, Lane K, McBee N, Ziai W, Mould WA, Iqbal A, Metcalfe S, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Zuccarello M, Mendelow AD, Hanley DF, Awad IA. Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials. Neurosurgery 2021; 88:961-970. [PMID: 33475732 DOI: 10.1093/neuros/nyaa572] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 06/30/2020] [Accepted: 11/12/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. OBJECTIVE To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. METHODS Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n = 84) were compared to STICH II all lobar cases (n = 259) for volumetric analyses. All MISTIE III surgical patients (n = 240) were compared to both STICH I and II (n = 722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. RESULTS End-of-treatment ICH volume ≤28.8 mL in MISTIE III and ≤30.0 mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180 d (P = .01 and P = .003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180 d with STICH I and II (P = .0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. CONCLUSION Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, UK
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ahmed Iqbal
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Stephen Metcalfe
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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15
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Kim H, Flemming K, Nelson J, Lui A, Majersik JJ, Zabramski J, Zafar A, Torbey MT, Mabray M, Robinson M, Thompson R, McBee N, Treine K, Stadnik A, Piedad K, Hobson N, Shkoukani A, Carrion Penagos J, Mendoza-Puccini C, Koenig JI, Hanley DF, Awad IA. Abstract P46: Baseline Characteristics of Patients With Cerebral Cavernous Angiomas With Symptomatic Hemorrhage in a Multisite Trial Readiness Study. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p46] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with cerebral cavernous angiomas with symptomatic hemorrhage (CASH) have high risk of disability from recurrent bleeding. Candidate medications to prevent rebleeding in CASH lesions will require multisite clinical trials with standardized data collection.
Objective:
To report the prevalence and baseline cohort features in CASH patients and establish a research network infrastructure for trials.
Methods:
This prospective observational cohort study includes adults with radiologically verified CASH lesion within 1-year of consent. Exclusions include prior or planned surgical intervention, spinal location, or prior brain irradiation. Six sites enrolled patients into the screening and clinical assessment portion of the study starting July 2018. Patients also had the option to participate in the follow up biomarker validation at 4 sites. Baseline demographics, clinical and imaging information, and outcomes (mRS, PROMIS-29, NIHSS, and EuroQol-5D) were collected. Biomarker imaging included dynamic contrast enhanced quantitative perfusion (DCEQP) and quantitative susceptibility mapping (QSM) that correlated with symptomatic bleeding. Descriptive statistics were performed and one-sample t-test was used to compare whether mean T-scores for PROMIS-29 domains differed significantly from a reference population.
Results:
As of May 2020, 849 CASH patients were screened of whom 110 (13%) were eligible and enrolled; 73 also enrolled into the biomarker validation study. Average age at enrollment was 46±16 years at a mean of 4.4 months after symptom onset; 53% were female, 41% were familial, and 43% of CASH lesions were brainstem location. At enrollment, 90% of the cohort had independent functional outcome (mRS ≤ 2 and NIHSS <5). Perceived health problems affecting QoL were reported in >30% (EuroQol-5D). CASH cases had significantly worse anxiety but better depression and social satisfaction scores compared to a general population (all P<0.01). Baseline DCEQP and QSM measures did not differ significantly across sites.
Conclusion:
We demonstrate feasibility of multisite recruitment of CASH patients and report prevalence of baseline features that will aid in design of clinical trials and inclusion of appropriate outcome measures.
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Murthy S, Roh DJ, Chatterjee A, McBee N, Parikh NS, Merkler AE, Navi BB, Falcone GJ, Sheth KN, Awad I, Hanley D, Kamel H, Ziai WC. Prior antiplatelet therapy and haematoma expansion after primary intracerebral haemorrhage: an individual patient-level analysis of CLEAR III, MISTIE III and VISTA-ICH. J Neurol Neurosurg Psychiatry 2020; 92:jnnp-2020-323458. [PMID: 33106367 PMCID: PMC8071838 DOI: 10.1136/jnnp-2020-323458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/22/2020] [Accepted: 06/04/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the relationship between prior antiplatelet therapy (APT) and outcomes after primary intracerebral haemorrhage (ICH), and assess if it varies by haematoma location. METHODS We pooled individual patient data from the Virtual International Stroke Trials Archive-ICH trials dataset, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III trial. The exposure was APT preceding ICH diagnosis. The primary outcome was haematoma expansion at 72 hours. Secondary outcomes were admission haematoma volume, all-cause mortality, death or major disability (modified Rankin Scale (mRS) score ≥4) and shift in mRS distribution. Mixed-effects models were used to assess the relationship between APT and outcomes. Secondary analyses were stratified by ICH location and study cohort. RESULTS Among 1420 patients with ICH, there were 782 (55.1%) lobar and 596 (42.0%) deep haemorrhages. APT was reported in 284 (20.0%) patients. In adjusted regression models, prior APT was not associated with haematoma expansion (OR, 0.97; 95% CI 0.60 to 1.57), major disability or death (OR, 1.05; 95% CI 0.61 to 1.63), all-cause mortality (OR, 0.89; 95% CI 0.47 to 1.85), admission haematoma volume (beta, -0.17; SE, 0.09; p=0.07) and shift in mRS (p=0.43). In secondary analyses, APT was associated with admission haematoma volume in lobar ICH (beta, 0.25; SE, 0.12; p=0.03), but there was no relationship with other ICH outcomes when stratified by haematoma location or study cohort. CONCLUSIONS In a large heterogeneous cohort of patients with ICH, prior APT was not associated with haematoma expansion or functional outcomes after ICH, regardless of haematoma location. APT was associated with admission haematoma volumes in lobar ICH.
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Affiliation(s)
- Santosh Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - David J Roh
- Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Nichol McBee
- Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Issam Awad
- Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurolgy, Weill Cornell Medicine, New York, NY, United States
| | - Wendy C Ziai
- Departments of Neurology, Neurosurgery, and Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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17
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Polster SP, Stadnik A, Akers AL, Cao Y, Christoforidis GA, Fam MD, Flemming KD, Girard R, Hobson N, Koenig JI, Koskimäki J, Lane K, Liao JK, Lee C, Lyne SB, McBee N, Morrison L, Piedad K, Shenkar R, Sorrentino M, Thompson RE, Whitehead KJ, Zeineddine HA, Hanley DF, Awad IA. Atorvastatin Treatment of Cavernous Angiomas with Symptomatic Hemorrhage Exploratory Proof of Concept (AT CASH EPOC) Trial. Neurosurgery 2020; 85:843-853. [PMID: 30476251 DOI: 10.1093/neuros/nyy539] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [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: 08/29/2018] [Accepted: 10/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND More than a million Americans harbor a cerebral cavernous angioma (CA), and those who suffer a prior symptomatic hemorrhage have an exceptionally high rebleeding risk. Preclinical studies show that atorvastatin blunts CA lesion development and hemorrhage through inhibiting RhoA kinase (ROCK), suggesting it may confer a therapeutic benefit. OBJECTIVE To evaluate whether atorvastatin produces a difference compared to placebo in lesional iron deposition as assessed by quantitative susceptibility mapping (QSM) on magnetic resonance imaging in CAs that have demonstrated a symptomatic hemorrhage in the prior year. Secondary aims shall assess effects on vascular permeability, ROCK activity in peripheral leukocytes, signal effects on clinical outcomes, adverse events, and prespecified subgroups. METHODS The phase I/IIa placebo-controlled, double-blinded, single-site clinical trial aims to enroll 80 subjects randomized 1-1 to atorvastatin (starting dose 80 mg PO daily) or placebo. Dosing shall continue for 24-mo or until reaching a safety endpoint. EXPECTED OUTCOMES The trial is powered to detect an absolute difference of 20% in the mean percent change in lesional QSM per year (2-tailed, power 0.9, alpha 0.05). A decrease in QSM change would be a signal of potential benefit, and an increase would signal a safety concern with the drug. DISCUSSION With firm mechanistic rationale, rigorous preclinical discoveries, and biomarker validations, the trial shall explore a proof of concept effect of a widely used repurposed drug in stabilizing CAs after a symptomatic hemorrhage. This will be the first clinical trial of a drug aimed at altering rebleeding in CA.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Gregory A Christoforidis
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - James I Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - James K Liao
- Section of Cardiology, Department of Medicine, The University of Chicago Medical Center, Illinois
| | | | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Nichol McBee
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Kristina Piedad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Matthew Sorrentino
- Section of Cardiology, Department of Medicine, The University of Chicago Medical Center, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Kevin J Whitehead
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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18
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Awad IA, Polster SP, Carrión-Penagos J, Thompson RE, Cao Y, Stadnik A, Money PL, Fam MD, Koskimäki J, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson BA, Mendelow AD, Zuccarello M, Hanley DF. Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure. Neurosurgery 2020; 84:1157-1168. [PMID: 30891610 DOI: 10.1093/neuros/nyz077] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [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: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. CONCLUSION This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.
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Affiliation(s)
- Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
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19
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Polster SP, Cao Y, Carroll T, Flemming K, Girard R, Hanley D, Hobson N, Kim H, Koenig J, Koskimäki J, Lane K, Majersik JJ, McBee N, Morrison L, Shenkar R, Stadnik A, Thompson RE, Zabramski J, Zeineddine HA, Awad IA. Trial Readiness in Cavernous Angiomas With Symptomatic Hemorrhage (CASH). Neurosurgery 2020; 84:954-964. [PMID: 29660039 DOI: 10.1093/neuros/nyy108] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [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: 02/22/2018] [Accepted: 03/06/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Brain cavernous angiomas with symptomatic hemorrhage (CASH) are uncommon but exact a heavy burden of neurological disability from recurrent bleeding, for which there is no proven therapy. Candidate drugs to stabilize the CASH lesion and prevent rebleeding will ultimately require testing of safety and efficacy in multisite clinical trials. Much progress has been made in understanding the epidemiology of CASH, and novel biomarkers have been linked to the biological mechanisms and clinical activity in lesions. Yet, the ability to enroll and risk-stratify CASH subjects has never been assessed prospectively at multiple sites. Biomarkers and other outcomes have not been evaluated for their sensitivity and reliability, nor have they been harmonized across sites. OBJECTIVE To address knowledge gaps and establish a research network as infrastructure for future clinical trials, through the Trial Readiness grant mechanism, funded by National Institute of Neurological Disorders and Stroke/National Institutes of Health. METHODS This project includes an observational cohort study to assess (1) the feasibility of screening, enrollment rates, baseline disease categorization, and follow-up of CASH using common data elements at multiple sites, (2) the reliability of imaging biomarkers including quantitative susceptibility mapping and permeability measures that have been shown to correlate with lesion activity, and (3) the rates of recurrent hemorrhage and change in functional status and biomarker measurements during prospective follow-up. EXPECTED OUTCOMES We propose a harmonized multisite assessment of enrollment rates of CASH, baseline features relevant to stratification in clinical trials, and follow-up assessments of functional outcomes in relation to clinical bleeds. We introduce novel biomarkers of vascular leak and hemorrhage, with firm mechanistic foundations, which have been linked to clinical disease activity. We shall test their reliability and validity at multiple sites, and assess their changes over time, with and without clinical rebleeds, hence their fitness as outcome instruments in clinical trials. DISCUSSION The timing cannot be more opportune, with therapeutic targets identified, exceptional collaboration among researchers and the patient community, along with several drugs ready to benefit from development of a path to clinical testing using this network in the next 5 years.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - James Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Joseph Zabramski
- Department of Neurological Surgery, The Barrow Neurological Institute, Phoenix, ArizonaAll except the first and final author are listed in alphabetic order
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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20
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Polster SP, Carrion-Penagos J, Gregson BA, Cao Y, Thompson RE, Stadnik A, Money PL, Koskimaki J, Lyne S, Fam MD, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Dawson J, Mendelow AD, Zuccarello M, Hanley DF, Awad IA. Abstract WMP103: Comparative Impact of Extent of Lobar Intracerebral Hemorrhage Removal on Outcome in the MISTIE III and STICH II Trials. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wmp103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III trial (MISTIE III) concluded that the extent of hematoma reduction confers a mortality and functional benefit. It is unclear if a minimum extent of evacuation is needed for mortality and functional outcome benefit in lobar cases with MISTIE and with open surgical interventions.
Objective:
We analyzed the effect of extent of lobar ICH evacuation on clinical outcome at 180 days after undergoing the MISTIE procedure and open craniotomy, in the context of the MISTIE III and STICH II clinical trials, respectively.
Methods:
Patients randomized to the surgical arm with lobar ICH, who underwent the procedure in the MISTIE III trial (n=84) and the STICH II trial (n=266) were analyzed, excluding cases crossing over to surgery. We assessed end of treatment ICH volume on post procedure CT scans and % hematoma evacuation, in relation to survival and likelihood of mRS 0-3. Cubic spline modeling with dichotomized outcome was used to compare the extent of hematoma evacuation on clinical outcome.
Results:
End of treatment volume of < 28 mL in lobar ICH MISTIE III patients and < 30 mL in STICH II trial patients showed a significantly increased probability of achieving an mRS of 0-3 at 180 days (p<0.03, p<0.006, respectively). This threshold was achieved in 83.1% of lobar cases undergoing MISTIE and in 92.1% of surgical cases in STICH II. Achieving survival benefit at 180 days trended towards improved probability with further hematoma volume reduction without a threshold value in MISTIE III, and was significant per mL reduction in STICH II (p<0.001). Analysis by percent of hematoma evacuation trended toward better probabilities of survival and improved functional outcome but were not significant.
Conclusion:
This analysis confirms that extent of hematoma evacuation is important in attaining the benefits of both minimally invasive and open surgical interventions in non-herniating lobar ICH patients randomized in clinical trials. Extent of ICH evacuation must be considered in the analysis of comparative effectiveness of various techniques and in the design of future trials.
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Affiliation(s)
- Sean P Polster
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | | | - Ying Cao
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Agnieszka Stadnik
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Janne Koskimaki
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Sean Lyne
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Maged D Fam
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Romuald Girard
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Karen Lane
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Nichol McBee
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Wendy Ziai
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Yi Hao
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Robert Dodd
- Neurosurgery, Stanford Univ Sch of Medicine, Stanford, CA
| | - Andrew P Carlson
- Neurosurgery, Univ of New Mexico Sch of Medicine, Albuquerque, NM
| | - Paul J Camarata
- Neurosurgery, Univ of Kansas Sch of Medicine, Kansas City, KS
| | | | - Mark R Harrigan
- Dept of Surgery, Section of Neurosurgery, Univ of Alabama at Birmingham, Birmingham, AL
| | - Jesse Dawson
- Institute of Cardiovascular and Med Sciences, Univ of Glasgow, Glasgow, United Kingdom
| | | | | | | | - Issam A Awad
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
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21
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Carhuapoma L, Avadhani R, Ostapkovich N, Lane K, McBee N, Carhuapoma JR, Ziai W, Awad I, Thompson RE, Hanley DF. Abstract 17: An Evaluation of Patient Disposition and Long-term Health-related Quality of Life In MISTIE III: Opportunities to Improve Decision Making for Critically Ill Intracerebral Hemorrhage Patients. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Recovery in intracerebral hemorrhage (ICH) is prolonged and unpredictable, resulting in challenges in estimating health-related quality of life (HRQoL). We describe HRQoL and patient disposition for ICH survivors with similar clinical characteristics to ICH patients who had withdrawal of life-sustaining treatment (WoLST).
Methods:
Using MISTIE III trial data (N = 499), we performed a matched cohort analysis using a published modified severity index (mSI) to compare ICH survivors (N = 379) with WoLST patients (N = 61). We used multivariable logistic regression adjusting for age, Glasgow Coma Score, deep ICH location, stability ICH and intraventricular hemorrhage volume and ≥ 3 comorbidities to create the mSI. After matching survivors with equal mSI to WoLST patients, we compared EuroQoL (EQ) visual analog scale (VAS) scores (US norm 69-76; range 0-100) by mSI quartile and patient disposition.
Results:
We matched 224 survivors to WoLST patients by mSI (range 0-6.5), with data at all timepoints. Given the large mSI range, EQ VAS scores and patient disposition were evaluated by mSI quartile groups. The median (interquartile range [IQR]) EQ VAS score increase for all mSI groups from day 30 (D30) to 180 (D180) was 20 (0-35.5,
p
< 0.0001), and 23.5 (5-40,
p
< 0.0001) for D30 to 365 (D365). The highest percentage of survivors for all mSI groups were home by D365 (G1 55%, G2 88%, G3 84.5%, G4 90%). Median (IQR) EQ VAS scores by mSI quartile, patient disposition and timepoint are reported below.
Conclusion:
ICH survivors, matching WoLST individuals, in all mSI groups demonstrated improvement in HRQoL over time, and the majority were home by D365. This study challenges current practice of identifying poor outcomes in concert with decision making employing WoLST in ICH. If goals of care are to include return to home and HRQoL, these results strongly suggest that prognostication can be improved. Prospective studies of ICH prognostication and decision making are needed.
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Affiliation(s)
- Lourdes Carhuapoma
- Anesthesiology/Critical Care Medicine, The Johns Hopkins Hosp, Baltimore, MD
| | | | | | - Karen Lane
- Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
| | - Nichol McBee
- Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
| | - Juan R Carhuapoma
- Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Univ, Baltimore, MD
| | - Wendy Ziai
- Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Daniel F Hanley
- Neurology and Anesthesiology/Critical Care Medicine, Div of Brain Injury Outcomes, Johns Hopkins Univ, Baltimore, MD
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22
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Ostapkovich N, Avadhani R, Carhuapoma L, Thompson RE, Lane K, McBee N, Ziai W, Awad I, Hanley D. Abstract 12: An Evaluation of Functional Outcome at 1 Year of Poor Prognosis Patients in Mistie-III. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Clinical factors impacting prognosis following Intracerebral Hemorrhage (ICH) have been well described in the literature, with “poor” prognosis often leading to withdrawing life sustaining treatments (WoLST). The MISTIE-III trial data provides an opportunity to review 12 month outcome of “poor" prognosis subjects.
Methods:
In order to evaluate functional recovery of ICH survivors compared with patients who had WoLST we used a severity index (SI) score for predicting good functional recovery 1 year following ICH. The SI used 6 clinical univariate variables from the MISTIE-III analysis (age
>
67, Glasgow Coma Score [GCS]
<
8, deep ICH location, stability ICH volume
>
45mL, stability intraventricular hemorrhage (IVH) volume>0.4mL) and
>
3 comorbidities (hypertension, hyperlipidemia, cardiovascular disease, and end-stage renal disease). Based on the SI scores for subjects who had WoLST, a matched cohort of survivors with “poor" prognosis (mRS 4-5) were tracked for functional recovery for 12 months.
Results:
Of the participants enrolled in MSITIE-III, 61 had WoLST. Of the non-WoLST ICH survivors, 16 progressed to death during the acute period. Another 48 had died prior to the 1 year (D365) follow up. At the 30 Day (D30) evaluation, there were 263 ICH survivors with “poor" prognosis SI scores having a mRS of 4 or 5 and 94% were still in a treatment facility. By D365, 47% of the “poor prognosis” patients had improved to mRS 0-3 (good outcome) with 98% living at home. Of the remaining, 36% had a mRS of 4 (moderately severe disability) with 64% living at home, and 17% had a mRS of 5 (severe disability) with 31% living at home.
Conclusion:
For family members of patients sustaining an ICH where clinical factors indicate a “poor" prognosis, the decision to continue or withdraw life sustaining treatment is difficult. Our data shows that ICH patients with clinical factors that are assumed to indicate “poor" prognosis for recovery can, when given time, achieve a favorable outcome.
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Affiliation(s)
| | | | | | | | - Karen Lane
- Neurology, Johns Hopkins Univ, Baltimore, MD
| | | | - Wendy Ziai
- Anes and Neuro Anesthesiology, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery and Neurology, Univ of Chicago, ChIcago, IL
| | - Dan Hanley
- Neurology, Johns Hopkins Univ, Baltimore, MD
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23
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Polster SP, Carrion-Penagos J, Gregson BA, Cao Y, Thompson RE, Stadnik A, Money PL, Koskimaki J, Lyne S, Fam MD, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Dawson J, Mendelow AD, Zuccarello M, Hanley DF, Awad IA. Abstract TP335: Comparative Impact of Timing From Ictus to Intracerebral Hemorrhage Evacuation on Outcome in MISTIE III, STICH I & II Trials. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Completion of the MISTIE procedure requires a period of hematoma stability before and during hematoma removal and, if necessary, dosing of rtPA which can take days to complete. Early surgery was intended in the STICH I and II trials, yet was performed after varying delays. No previous analysis has evaluated the timing for hematoma removal on outcomes in these trials.
Objective:
Determine if time from ictus to completion of hematoma removal may have affected patient outcome in three large surgical clinical trials of ICH evacuation.
Methods:
Patients randomized to surgery in the MISTIE III (n=242), STICH I (n=464) and STICH II (n=266) trials who received the procedure were analyzed, excluding cases crossing over to surgery. Time from ictus to end of treatment, defined as 24 hours after last dose in (MISTIE III) or time to craniotomy (STICH I and II), was analyzed in relation to likelihood of survival and functional outcome at 180 days. Cubic spline models with dichotomized outcomes were used.
Results:
The probability of achieving an mRS 0-3 increased significantly with longer time until completion of the procedure, up to 83 hours post-ictus, and worsened with longer delays thereafter (p=0.05). Better mRS was also achieved in STICH I patients with longer time until surgical removal, up to 60 hours post-ictus (p=0.0002), but not with longer delays (p=0.49). In STICH II (lobar cases), there was greater likelihood of mRS 0-3 with longer delay after 22 hours post-ictus (p=0.004), but not with earlier surgery (p=0.19). There was no significant benefit in survival, with earlier intervention across modalities and trials. Adjustment by initial hematoma volume further validated that early procedures do not favor survival or achieving a mRS 0-3.
Conclusion:
Early hematoma evacuation up to 60-80 hours post-ictus does not increase the probability of survival nor a good functional outcome in non-herniating ICH patients included in clinical trials, likely in view of bleeding instability. This was true in minimally invasive intervention as well as open surgeries.
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Affiliation(s)
- Sean P Polster
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | | | - Ying Cao
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Agnieszka Stadnik
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | | | - Janne Koskimaki
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Sean Lyne
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Maged D Fam
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Romuald Girard
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
| | - Karen Lane
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Nichol McBee
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Wendy Ziai
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Yi Hao
- Neurology, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Robert Dodd
- Neurosurgery, Stanford Univ Sch of Medicine, Stanford, CA
| | - Andrew P Carlson
- Neurosurgery, Univ of New Mexico Sch of Medicine, Albuquerque, NM
| | - Paul J Camarata
- Neurosurgery, Univ of Kansas Sch of Medicine, Kansas City, KS
| | | | - Mark R Harrigan
- Dept of Surgery, Section of Neurosurgery, Univ of Alabama at Birmingham, Birmingham, AL
| | - Jesse Dawson
- Institute of Cardiovascular and Med Sciences, Univ of Glasgow, Glasgow, United Kingdom
| | | | | | | | - Issam A Awad
- Dept of Surgery, Section of Neurosurgery, Univ of Chicago, Chicago, IL
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24
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Müller A, Mould WA, Freeman WD, McBee N, Lane K, Dlugash R, Thompson R, Nekoovaght-Tak S, Madan V, Ali H, Stadnik A, Awad I, Hanley D, Ziai WC. The Incidence of Catheter Tract Hemorrhage and Catheter Placement Accuracy in the CLEAR III Trial. Neurocrit Care 2019; 29:23-32. [PMID: 29294223 DOI: 10.1007/s12028-017-0492-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Incidence of catheter tract hemorrhage (CTH) after initial ventriculostomy placement ranges from 10 to 34%. We investigated CTH incidence in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III trial. METHODS Prospective observational analysis of 1000 computer tomography (CT) scans from all 500 patients enrolled in the trial. All catheters were evaluated on first CT post-placement and on last CT prior to randomization for placement location and CTH size, location, and severity. Clinical variables were assessed for association with CTH with multivariable logistic regression. RESULTS Of 563 catheters, CTH was detected in 14 and 21% of patients on first and last CT (median 3.7 and 43.4 h after catheter placement, respectively). All, but one were asymptomatic. Majority of CTH (86%) occurred within 24 h after placement, were located within 1 cm of the skull, and had at least one diameter > 5 mm. Most catheters (71%) terminated in the third or lateral ventricle ipsilateral to insertion site. Factors significantly associated with CTH were pre-admission use of antiplatelet drugs, accuracy of catheter placement, non-operating room catheter placement, Asian race, and intraventricular hemorrhage expansion. CONCLUSIONS CTH incidence on initial catheter placement and during stabilization was relatively low, despite emergent placement in a high-risk population. Catheter placement accuracy was similar or better than convenience samples from the published literature. Decreasing risk of CTH may be achieved with attention to catheter placement accuracy and placement in the operating room. Antiplatelet agent use was an independent risk factor for CTH.
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Affiliation(s)
- Achim Müller
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W David Freeman
- Department of Neurology, Neurosurgery, and Critical Care, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Nichol McBee
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rick Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Saman Nekoovaght-Tak
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vikram Madan
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hasan Ali
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Agnieszka Stadnik
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Departments of Neurology, Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St./Phipps 455, Baltimore, MD, 21287, USA.
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Fam MD, Stadnik A, Zeineddine HA, Girard R, Mayo S, Dlugash R, McBee N, Lane K, Mould WA, Ziai W, Hanley D, Awad IA. Symptomatic Hemorrhagic Complications in Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III Clinical Trial (CLEAR III): A Posthoc Root-Cause Analysis. Neurosurgery 2019; 83:1260-1268. [PMID: 29294116 DOI: 10.1093/neuros/nyx587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As intraventricular thrombolysis for intraventricular hemorrhage (IVH) has developed over the last 2 decades, hemorrhagic complications have remained a concern despite general validation of its safety in controlled trials in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program. OBJECTIVE To analyze factors associated with symptomatic bleeding following IVH with and without thrombolysis in conjunction with the recently completed CLEAR III trial. METHODS We reviewed safety reports on symptomatic bleeding events reported during the first year after randomization among subjects enrolled in the CLEAR III trial. Clinical and imaging data were retrieved through the trial database as part of ongoing quality and safety monitoring. A posthoc root-cause analysis was performed to identify potential factors predisposing to rebleeding in each case. Cases were classified according to onset of rebleeding (during dosing, early after dosing and delayed), the pattern of bleeding, and treatment rendered (alteplase vs saline). RESULTS Twenty subjects developed a secondary symptomatic intracranial hemorrhage constituting 4% of subjects. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy resulted from a combination of treatment- and patient-related factors and were at most partially attributable to alteplase. Rebleeding after the dosing protocol primarily reflected patients' risk factors. CONCLUSION Intraventricular thrombolysis marginally increases the overall risk of symptomatic hemorrhagic complications after IVH, and only during the treatment phase.
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Affiliation(s)
- Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
| | | | - Rachel Dlugash
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Nichol McBee
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Karen Lane
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - W Andrew Mould
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Wendy Ziai
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Hanley
- Brain Injury Outcomes Unit, Johns Hopkins University, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine, Chicago, Illinois
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26
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Eslami V, Tahsili-Fahadan P, Rivera-Lara L, Gandhi D, Ali H, Parry-Jones A, Nelson LS, Thompson RE, Nekoobakht-Tak S, Dlugash R, McBee N, Awad I, Hanley DF, Ziai WC. Influence of Intracerebral Hemorrhage Location on Outcomes in Patients With Severe Intraventricular Hemorrhage. Stroke 2019; 50:1688-1695. [PMID: 31177984 DOI: 10.1161/strokeaha.118.024187] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- We investigated the prognostic significance of spontaneous intracerebral hemorrhage location in presence of severe intraventricular hemorrhage. Methods- We analyzed diagnostic computed tomography scans from 467/500 (excluding primary intraventricular hemorrhage) subjects from the CLEAR (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) III trial. We measured intracerebral hemorrhage engagement with specific anatomic regions, and estimated association of each region with blinded assessment of dichotomized poor stroke outcomes: mortality, modified Rankin Scale score of 4 to 6, National Institutes of Health Stroke Scale score of >4, stroke impact scale score of <60, Barthel Index <86, and EuroQol visual analogue scale score of <50 and <70 at days 30 and 180, respectively, using logistic regression models. Results- Frequency of anatomic region involvement consisted of thalamus (332 lesions, 71.1% of subjects), caudate (219, 46.9%), posterior limb internal capsule (188, 40.3%), globus pallidus/putamen (127, 27.2%), anterior limb internal capsule (108, 23.1%), and lobar (29, 6.2%). Thalamic location was independently associated with mortality (days 30 and 180) and with poor outcomes on most stroke scales at day 180 on adjusted analysis. Posterior limb internal capsule and globus pallidus/putamen involvement was associated with increased odds of worse disability at days 30 and 180. Anterior limb internal capsule and caudate locations were associated with decreased mortality on days 30 and 180. Anterior limb internal capsule lesions were associated with decreased long-term morbidity. Conclusions- Acute intracerebral hemorrhage lesion topography provides important insights into anatomic correlates of mortality and functional outcomes even in severe intraventricular hemorrhage causing obstructive hydrocephalus. Models accounting for intracerebral hemorrhage location in addition to volumes may improve outcome prediction and permit stratification of benefit from aggressive acute interventions. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT00784134.
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Affiliation(s)
- Vahid Eslami
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Pouya Tahsili-Fahadan
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.).,Neuroscience Intensive Care Unit, Department of Neurology, Virginia Commonwealth University, Falls Church (P.T.-F.)
| | - Lucia Rivera-Lara
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Dheeraj Gandhi
- Department of Neuroradiology, University of Maryland, Baltimore (D.G.)
| | - Hasan Ali
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Adrian Parry-Jones
- School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, United Kingdom (A.P.-J., L.S.N.)
| | - Lilli S Nelson
- School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, United Kingdom (A.P.-J., L.S.N.)
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (R.E.T.)
| | - Saman Nekoobakht-Tak
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Isaam Awad
- Department of Neurological Surgery, University of Chicago Medicine, IL (I.A.)
| | - Daniel F Hanley
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
| | - Wendy C Ziai
- From the Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (V.E., P.T.-F., L.R.-L., D.F.H., W.C.Z.).,Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University, Baltimore, MD (V.E., P.T.-F., L.R.-L., H.A., S.N.-T., R.D., N.M., D.F.H., W.C.Z.)
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27
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Ziai WC, McBee N, Lane K, Lees KR, Dawson J, Vespa P, Thompson RE, Mendelow AD, Kase CS, Carhuapoma JR, Thompson CB, Mayo SW, Reilly P, Janis S, Anderson CS, Harrigan MR, Camarata PJ, Caron JL, Zuccarello M, Awad IA, Hanley DF. A randomized 500-subject open-label phase 3 clinical trial of minimally invasive surgery plus alteplase in intracerebral hemorrhage evacuation (MISTIE III). Int J Stroke 2019; 14:548-554. [PMID: 30943878 DOI: 10.1177/1747493019839280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
RATIONALE AND HYPOTHESIS Surgical removal of spontaneous intracerebral hemorrhage may reduce secondary destruction of brain tissue. However, large surgical trials of craniotomy have not demonstrated definitive improvement in clinical outcomes. Minimally invasive surgery may limit surgical tissue injury, and recent evidence supports testing these approaches in large clinical trials. METHODS AND DESIGN MISTIE III is an investigator-initiated multicenter, randomized, open-label phase 3 study investigating whether minimally invasive clot evacuation with thrombolysis improves functional outcomes at 365 days compared to conservative management. Patients with supratentorial intracerebral hemorrhage clot volume ≥ 30 mL, confirmed by imaging within 24 h ofknown symptom onset,and intact brainstem reflexes were screened with a stability computed tomography scan at least 6 h after diagnostic scan. Patients who met clinical and imaging criteria (no ongoing coagulopathy; no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly; and stable hematoma size on consecutive scans) were randomized to either minimally invasive surgery plus thrombolysis or medical therapy. The sample size of 500 was based on findings of a phase 2 study. STUDY OUTCOMES The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 365 days adjusting for severity variables. Clinical secondary outcomes include dichotomized extended Glasgow Outcome Scale and all-cause mortality at 365 days; rate and extent of parenchymal blood clot removal; patient disposition at 365 days; efficacy at 180 days; type and intensity of ICU management; and quality of life measures. Safety was assessed at 30 days and throughout the study.
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Affiliation(s)
- Wendy C Ziai
- 1 Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Nichol McBee
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Lane
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Kennedy R Lees
- 3 School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- 4 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul Vespa
- 5 Department of Neurosurgery, University of California, Los Angeles, CA, USA
| | - Richard E Thompson
- 6 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A David Mendelow
- 7 Department of Neurosurgery, Newcastle University, Newcastle upon Tyne, UK
| | - Carlos S Kase
- 8 Department of Neurology, Emory University, Atlanta, GA, USA
| | - J Ricardo Carhuapoma
- 1 Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Carol B Thompson
- 9 Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Pat Reilly
- 11 Genentech Inc., San Francisco, CA, USA (retired).,12 Jamison-Reilly LLC, Hummelstown, PA, USA
| | - Scott Janis
- 13 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Craig S Anderson
- 14 The George Institute for Global Health China at Peking University Health Science Center, Beijing, China.,15 The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mark R Harrigan
- 16 Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Paul J Camarata
- 17 Department of Neurosurgery, University of Kansas, Kansas City, KS, USA
| | - Jean-Louis Caron
- 18 Department of Neurosurgery, University of Texas, San Antonio, TX, USA
| | - Mario Zuccarello
- 19 Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Issam A Awad
- 20 Section of Neurosurgery, Neurovascular Surgery Program, University of Chicago, Chicago, IL, USA
| | - Daniel F Hanley
- 2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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28
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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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Murthy SB, Roh D, Chatterjee A, Chen M, Dlugash R, McBee N, ElJalby M, Merkler A, Navi B, Awad I, Hanley D, Sheth K, Kamel H, Ziai W. Abstract WMP100: Prior Antiplatelet Use and Outcomes After Lobar, Deep, and Intraventricular Hemorrhage. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
We examined the association between prior antiplatelet therapy and outcomes in patients with lobar versus deep intracerebral hemorrhage (ICH) versus intraventricular hemorrhage (IVH).
Methods:
We performed a retrospective cohort study using data from patients with lobar and deep ICH registered in the Virtual International Stroke Trials Archive (VISTA-ICH), and patients with IVH enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. We excluded patients in the intervention arms of the trials, and those on prior anticoagulation therapy. The exposure was antiplatelet therapy prior to ICH/IVH. Primary outcomes were hematoma expansion and death/major disability in the VISTA-ICH cohort, and ventriculostomy tract hemorrhage, hematoma expansion, and death/major disability in the CLEAR III cohort. We used separate sets of logistic regression models in each group—lobar ICH, deep ICH, and IVH—to examine the association between antiplatelet therapy and our outcomes.
Results:
Among 548 ICH patients in the VISTA-ICH cohort, there were 416 (75.9%) lobar and 121 (22.1%) deep hematomas. Median baseline ICH volumes were 19 ml (IQR, 11-26) in lobar and 8 ml (IQR, 4-13) in deep bleeds. Prior antiplatelet therapy was reported in 92 patients with lobar (22.1%) and 26 patients (20.8%) patients with deep ICH. After adjustment for demographics, comorbidities, and hematoma characteristics, antiplatelet therapy was not associated with hematoma expansion or poor functional outcomes after lobar (OR, 0.8; 95% CI, 0.5-1.8) or deep (OR, 1.3; 95% CI, 0.4-3.8) ICH. In the CLEAR cohort, the 62 of 222 IVH patients (27.9%) with prior antiplatelet therapy had similar odds of hematoma expansion (OR, 0.6; 95% CI, 0.2-1.7) or poor functional outcomes (OR, 0.9; 95% CI, 0.4-2.1), but higher odds of ventriculostomy tract hemorrhage (OR, 3.2; 95% CI, 1.3-7.7).
Conclusions:
Prior antiplatelet therapy was not associated with hematoma expansion or functional outcomes after lobar or deep ICH or IVH, but was associated with ventriculostomy tract hemorrhage.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - David Roh
- Neurology, Columbia Univ College of Physicians and Surgeons, New York, NY
| | - Abhinabha Chatterjee
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Monica Chen
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Rachel Dlugash
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
| | - Nichol McBee
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
| | - Mahmoud ElJalby
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Alexander Merkler
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Babak Navi
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Issam Awad
- Neurological Surgery, Univ of Chicago, Chicago, IL
| | - Daniel Hanley
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
| | - Kevin Sheth
- Neurology, Yale Univ Sch of Medicine, New Haven, CT
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Wendy Ziai
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
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30
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Mould WA, Muschelli J, Avadhani R, McBee N, Lane K, Thompson R, Ziai W, Zuccarello M, Awad I, Hanley DF. Abstract 15: Reduction in Perihematomal Edema Leads to Improved Clinical Outcomes: Results from the MISTIE III Trial. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - John Muschelli
- Johns Hopkins Bloomberg Sch of Public Health, Baltimore, MD
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31
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Avadhani R, Thompson RE, Yenokyan G, Lane K, McBee N, Ziai WC, Awad IA, Hanley DF. Abstract WP556: Predicting Modified Rankin Scale Using Prior Cognition Measure: Results From CLEAR III Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intraventricular hemorrhage (IVH) is a subtype of intracerebral hemorrhage (ICH) accounting for 50% mortality and serious survivor disability. We examined whether screening Mini-Mental State Examination (MMSE) scores assessed at days 30 and/or 180 could predict good functional outcome, measured by modified Rankin Scale (mRS) at days 180 and 365 post-stroke.
Methodology:
CLEAR III was a multicenter, randomized, phase III trial that tested the benefits of accelerated IVH clot removal. Patients were followed for one year with MMSE and mRS collected at days 30 (D30), 180 (D180) and 365 (D365). Good functional outcome was defined as mRS 0-3. Of 500 patients randomized, 354 known survivors were analyzed. Multivariate logistic regression (MLR) was used to estimate the relationship between good D180 and D365 mRS and D30 and/or D180 MMSE adjusting for age and any ICH location.
Results:
The model predicted a 15% increase in the odds of good D180 mRS for each unit increase in D30 MMSE (OR [95% CI] =1.15 [1.11, 1.20], p-value<0.001). Based on this model, a score of MMSE of 14 or higher is associated with good D180 mRS with 77% sensitivity, 75% specificity, and 76% correctly classified cases (AUC=0.84). In MLR model, D30 MMSE (AOR [95% CI]=1.14 [1.10, 1.19], p-value<0.001) and thalamus ICH location (AOR [95% CI]=0.18 [0.09, 0.38], p-value<0.001) were significant predictors of good D180 mRS, with no significant association with age (AOR [95% CI]=0.97 [0.94, 1.00], p-value=0.073). Similarly, we saw a 14% increase (AOR [95% CI]=1.14, [1.09, 1.20], p-value<0.001) in the odds of good D365 mRS for each unit increase in D30 MMSE, and 9% increase (AOR [95% CI]=1.09, [1.03, 1.15], p-value=0.002) in the odds of good D365 mRS for each unit increase in D180 MMSE (p-value <0.001, AUC=0.88). D30 MMSE (AOR [95% CI]=1.12 [1.06, 1.18], p-value<0.001), D180 MMSE (AOR [95% CI]=1.12 [1.05, 1.19], p-value=0.001), age (AOR [95% CI]=0.96 [0.92, 1.00], p-value=0.041), and thalamus ICH location (AOR [95% CI]=0.17 [0.07, 0.44], p-value<0.001) were significantly associated with good D365 mRS.
Conclusion:
Cognition measurements, such as MMSE, may be helpful in predicting good functional outcomes at D180 and D365 post-stroke.
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Affiliation(s)
- Radhika Avadhani
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Richard E Thompson
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Gayane Yenokyan
- Dept of Biostatistics, Johns Hopkins Bloomberg Sch of Public Health, Baltimore, MD
| | - Karen Lane
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Nichol McBee
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
| | - Wendy C Ziai
- Dept of Neurology - Div of Neurosciences Critical Care, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Issam A Awad
- Dept of Neurological Surgery, Univ of Chicago Medicine, Chicago, IL
| | - Daniel F Hanley
- Dept of Neurology - Div of Brain Injury Outcomes, Johns Hopkins Univ Med Insts, Baltimore, MD
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Lane K, Keita M, Avadhani R, Dlugash R, Mayo S, Thompson RE, Awad I, McBee N, Ziai W, Hanley DF. African American Screening and Enrollment in (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III) CLEAR III. Clin Res (Alex) 2018; 32:https://www.acrpnet.org/2018/08/14/african-american-screening-and-enrollment-in-the-clear-iii-trial/. [PMID: 30221183 PMCID: PMC6138411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Under-enrolling minority patients in clinical trials reduces generalizability. CLEAR III, a randomized controlled trial, presented an opportunity to assess African American (AA) participation. METHODS AA enrollment was compared to U.S. population and NINDS trial data then stratified by region; census data for 42 recruitment cities were compared to screening and randomization percentages, using simple linear regression. RESULTS AAs were 25% of screens and 45.1% of enrollments (n=370), more than twice the 19.8% participation rate reported by the 2011 NINDS Advisory Panel on Health Disparities Research and triple the projected 13.9% 2014 U.S. population. Conversion rates were (AA vs. non-AA): overall (8.7% vs. 3.4%, p<0.001); Northeast (7.7% vs. 2.9%, p<0.001); South (8.2% vs. 4.0%, p<0.001); Midwest (10.3% vs. 3.6%, p<0.01); and West (8.9% vs. 3.8%, p=0.02). AA enrollments ranged from 0% to 100% (mean: 40.4%). AA screening ranged from 0% to 63.7% (mean: 23.2%). AA city census ranged from 1.3% to 82.7% (mean: 28.0%); higher census was associated with higher screening (p<0.0001) and enrollment (p=0.004). CONCLUSIONS AAs were willing to enroll in an acute stroke trial. AA city census rates should be considered when selecting enrollment centers and setting recruitment goals. Factors leading to successful AA recruitment should be further investigated, as population-based participation is a goal in all trials.
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Affiliation(s)
- Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maningbe Keita
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Dlugash
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven Mayo
- Emissary International, LLC, Austin, TX, USA
| | | | - Issam Awad
- University of Chicago Medicine and Biological Sciences, Chicago, IL, USA 60637
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, 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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Tahsili-Fahadan P, Eslami V, Rivera-Lara L, Thompson CB, Dlugash R, McBee N, Awad I, Hanley DF, Ziai WC. Abstract WP338: Effect of Thalamic Hemorrhage Localization on Level of Consciousness and Functional Outcomes in the CLEAR III Trial. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Thalamic hemorrhages account for 10-15% of intracerebral hemorrhages (ICH) and have a variety of clinical manifestations. We investigated the relationship between injury to thalamus and intra-thalamic regions with level of consciousness and functional outcomes among CLEAR-III trial participants.
Methods:
We analyzed diagnostic CT scans of 500 patients from CLEAR-III trial prior to randomization and identified the anatomic localization of ICH. Thalamic hemorrhages were further divided into 5 groups: dorsal, anterior, medial, central, and posterolateral. Blinded level of consciousness measures (Glasgow Coma Score (GCS) and question 1a of the National Institutes of Health Stroke Scale (NIHSS)) and stroke severity indices (including mortality and modified Rankin Scale (mRS)) were analyzed. We assessed association of each region with level of consciousness and stroke severity measures using multivariate logistic regression models. Major disability was defined as mRS 4-5. Outcome models were adjusted for ICH volume, IVH (intraventricular hemorrhage) volume, and age.
Results:
Thalamic ICH was present in 332 patients (71%, 33 with primary IVH were excluded). Initial median GCS was similar in patients with (10, IQR 7-14) and without (10, IQR 6-14) thalamic lesion (P=0.72). At day 30 and 180, thalamic ICH was associated with increased mortality (OR 2.48, CI 0.92-6.63 and OR 2.03, CI 1.02-4.06), major disability (OR 2.44, CI 0.87-6.81 and OR 2.50, CI 1.08-5.75), and death or major disability (OR 2.57, CI 0.91-7.19 and OR 2.71, CI 1.37-5.38), respectively. Thalamic ICH involved medial, central, posterolateral, dorsal, and anterior regions in 51.8%, 48.8%, 48.6%, 56.8%, and 47% of cases, respectively. On day 7, only involvement of the medial thalamus was associated with decreased consciousness defined as GCS <=8 and NIHSS question 1a>=2 (P=0.024 and 0.043, respectively). While all thalamic regions were associated with worse mRS, none were associated with decreased consciousness at day 180.
Conclusion:
Thalamic hemorrhages are associated with poor functional outcomes. Medial thalamus involvement affects consciousness acutely but not in the long term. The mechanism by which medial thalamus alters consciousness merits investigation.
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Affiliation(s)
- Pouya Tahsili-Fahadan
- Dept of Anesthesiology and Critical Care Medicine, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Vahid Eslami
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Lucia Rivera-Lara
- Dept of Anesthesiology and Critical Care Medicine, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | | | - Nichol McBee
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | | | - Wendy C Ziai
- Dept of Anesthesiology and Critical Care Medicine, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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Murthy SB, Dlugash R, McBee N, Awad I, Hanley DF, Ziai WC. Abstract WMP108: Defining Optimal Thresholds for Achieving Clinical Benefit in Spontaneous Intraventricular Hemorrhage. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wmp108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Fibrinolytic therapy for spontaneous intraventricular hemorrhage (IVH) appears to reduce mortality with uncertain benefit on long-term functional outcomes. Threshold for volume of IVH which responds to intraventricular fibrinolytic therapy with therapeutic benefit has not been determined.
Methods:
CLEAR III, a randomized, multi-center, double-blinded, placebo-controlled trial was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular Alteplase improved outcome, in comparison to EVD plus saline. We analyzed of IVH volume strata from study randomization: Large IVH: volume ≥50 mL; small IVH: volume<20 mL. We assessed clinical variables and outcomes by IVH volume group. Outcome measures were blinded assessment of modified Rankin score (mRS) at 30, 180 and 365 days, (with mRS>3 signifying poor outcome). We performed logistic regression to evaluate outcomes by IVH volume group.
Results:
Among the 500 patients enrolled, 55 (11%) had IVH volumes >50 mL and 222 (44.4%) had IVH volume <20mL. Subjects with large volume IVH were older (mean, 62.3 vs. 58.1 years; p=0.01), had smaller ICH volume (6.1 vs. 9.9 mL; p<0.001), less thalamic ICH (16.4% vs. 63.6%; p<0.001), more pre-admission use of anticoagulants and antiplatelet agents and greater proportion of high intracranial pressure readings during monitoring at all thresholds (>20, 30, 40 mmHg), compared to those with IVH volume <50mL. Day 180 mortality and poor mRS were 49.1% and 81.8% in large volume IVH compared to 13.1% and 43.3% in small volume IVH. In logistic regression models adjusted for confounders, drainage of >85% IVH volume was significantly associated with higher odds of good outcome (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3) and lower odds of mortality (OR, 0.3; 95% CI, 0.1-0.8) compared to <85% drainage, in patients with baseline volumes <50mL. Removal of >85% IVH volume (n=3/55) was not associated with improved outcomes in patients with large IVH.
Conclusions:
IVH volume >50mL may represent a cohort without identified benefit from fibrinolytic treatment. Defining an upper limit for IVH volume would benefit from a larger sample and other methods of achieving IVH reduction.
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Affiliation(s)
| | - Rachel Dlugash
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
| | - Nichol McBee
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
| | - Isaam Awad
- Neurosurgery, Univ of Chicago Sch of Medicine, Chicago, IL
| | - Daniel F Hanley
- Brain Injury Outcomes Cntr, Johns Hopkins Univ, Baltimore, MD
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Shah VA, Yenokyan G, Dlugash R, McBee N, Awad I, Hanley DF, Ziai WC. Abstract TP348: Predicting 365 Day Outcomes for Spontaneous Intracerebral Hemorrhage And Intraventricular Hemorrhage Survivors With Poor Outcome on Day 30. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Prediction of long-term functional outcome in spontaneous intracerebral and intraventricular hemorrhage (ICH/IVH) is typically based on a limited number of severity factors known on admission. We investigated whether factors known at day 30 including medical comorbidities and in-hospital events in poor outcome survivors could accurately predict good vs. poor functional outcome at day 365.
Methods:
We explored the relationship between ICH severity factors, medical comorbidities, prospectively collected and adjudicated events during first 30 days post ictus, and outcomes using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with Alteplase (CLEAR III) trial. We defined outcome using blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 365 days (>3 signifying poor outcome). Multivariable logistic regression was used to predict mRS at day 365 from poor outcome survivors at day 30.
Results:
Of 500 patients included in CLEAR III with ICH and severe IVH requiring external ventricular drainage, 345 (69%) had mRS 4 or 5 on day 30. The best performing model for distinguishing between patients with and without good outcome at 365 days included: age (Odds Ratio [OR], 0.93; 95% Confidence Interval [CI], 0.90- 0.96), COPD (OR, 0.17; CI, 0.04-0.80), diabetes (OR, 0.50; CI, 0.25-0.98), hyperlipidemia (OR, 2.07; CI, 1.01-4.27), bacterial ventriculitis (OR, 0.34; CI, 0.13-0.91), cerebral perfusion pressure <50 mmHg during first week (OR, 0.08; CI, 0.01-0.50), absent IVH on day 30 CT scan (OR, 3.08; CI, 1.69-5.62), enrollment (e) eICH volume (OR, 0.91; CI, 0.87-0.95), eIVH volume (OR, 0.97; CI, 0.95-0.99), thalamic ICH location (OR, 0.29; CI, 0.14-0.60), and eGlasgow Coma Scale (OR, 1.15; CI, 0.1.06-1.26). Cross-validated area under ROC curve (95%CI) was 0.81 (0.77-0.86) vs. 0.78 (0.73-0.82) for standard ICH prediction model with only enrollment predictors.
Conclusions:
Among patients with spontaneous ICH and IVH requiring external ventricular drainage, 30-day prediction models for long-term functional outcomes have substantial predictive capability. Addition of medical comorbidities and in-hospital events to models using well-known ICH severity factors is of some value.
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Affiliation(s)
- Vishank A Shah
- Div of Neurocritical Care, Dept of Anesthesiology and Critical Care Medicine, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | - Rachel Dlugash
- Div of Brain Injury Outcomes, Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Nichol McBee
- Div of Brain Injury Outcomes, Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | - Daniel F Hanley
- Div of Brain Injury Outcomes, Dept of Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Wendy C Ziai
- Div of Neurocritical Care, Dept of Anesthesiology and Critical Care Medicine, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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Fam MD, Zeineddine HA, Eliyas JK, Stadnik A, Jesselson M, McBee N, Lane K, Cao Y, Wu M, Zhang L, Thompson RE, John S, Ziai W, Hanley DF, Awad IA. CSF inflammatory response after intraventricular hemorrhage. Neurology 2017; 89:1553-1560. [PMID: 28887375 DOI: 10.1212/wnl.0000000000004493] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To investigate the temporal pattern and relevant associations of CSF inflammatory measures after intraventricular hemorrhage (IVH). METHODS We analyzed prospectively collected CSF cell counts and protein and glucose levels from participants in the Clot Lysis Evaluation of Accelerated Resolution of IVH phase III (CLEAR III) trial. Corrected leukocyte count and cell index were calculated to adjust for CSF leukocytes attributable to circulating blood. Data were chronologically plotted. CSF inflammatory measures (daily, mean, median, maximum, and cases with highest quartile response) were correlated with initial IVH volume, IVH clearance rate, thrombolytic treatment, bacterial infection, and adjudicated clinical outcome at 30 and 180 days. RESULTS A total of 11,376 data points of CSF results from 464 trial participants were analyzed. Measures of CSF inflammatory response evolved during the resolution of IVH. This was significantly more pronounced with initial IVH volume exceeding 20 mL. Intraventricular alteplase was associated with a significantly augmented inflammatory response compared to saline, even after correcting for initial IVH volume. There was an association but nonpredictive correlation of CSF inflammation measures with culture-positive CSF bacterial infection. None of the CSF inflammatory measures, including cases with upper quartile inflammatory response, was associated with a significant detrimental effect on 30 or 180 days functional outcome or mortality after multivariate adjustment for measures of disease severity. CONCLUSIONS Aseptic CSF inflammation after IVH is primarily dependent on the volume of initial bleed. Thrombolysis intensifies the inflammatory response, with no apparent detrimental effect on clinical outcome. CLINICALTRIALSGOV IDENTIFIER NCT00784134.
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Affiliation(s)
- Maged D Fam
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Hussein A Zeineddine
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Javed Khader Eliyas
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Agnieszka Stadnik
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Michael Jesselson
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Nichol McBee
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Karen Lane
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Ying Cao
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Meijing Wu
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Lingjiao Zhang
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Richard E Thompson
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Sayona John
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Wendy Ziai
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Daniel F Hanley
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL
| | - Issam A Awad
- From the Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery (M.D.F., H.A.Z., J.K.E., A.S., M.J., Y.C., M.W., L.Z., Y.C., M.W., L.Z., I.A.A.), University of Chicago Medicine and Biological Sciences, IL; Brain Injury Outcomes (BIOS) Division, Department of Neurology (N.M., K.L., W.Z., D.F.H.), and The Bloomberg School of Public Health (R.E.T.), Johns Hopkins University Medical Institutions, Baltimore, MD; and Department of Neurology (S.J.), Rush University Medical Center, Chicago, IL.
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Zeineddine HA, Girard R, Cao Y, Hobson N, Fam MD, Stadnik A, Tan H, Shen J, Chaudagar K, Shenkar R, Thompson RE, McBee N, Hanley D, Carroll T, Christoforidis GA, Awad IA. Quantitative susceptibility mapping as a monitoring biomarker in cerebral cavernous malformations with recent hemorrhage. J Magn Reson Imaging 2017; 47:1133-1138. [PMID: 28791783 DOI: 10.1002/jmri.25831] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 06/14/2017] [Accepted: 07/24/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Quantitative Susceptibility Mapping (QSM) MRI allows accurate assessment of iron content in cerebral cavernous malformations (CCM), and a threshold increase by 6% in QSM has been shown to reflect new symptomatic hemorrhage (SH) in previously stable lesions. PURPOSE/HYPOTHESIS It is unclear how lesional QSM evolves in CCMs after recent SH, and whether this could serve as a monitoring biomarker in clinical trials aimed at preventing rebleeding in these lesions. STUDY TYPE This is a prospective observational cohort study. POPULATION 16 CCM patients who experienced a SH within the past year, whose lesion was not resected or irradiated. FIELD STRENGTH/SEQUENCE The data acquisition was performed using QSM sequence implemented on a 3T MRI system ASSESSMENT: The lesional QSM assessments at baseline and yearly during 22 patient-years of follow-up were performed by a trained research staff including imaging scientists. STATISTICAL TESTS Biomarker changes were assessed in relation to clinical events. Clinical trial modeling was performed using two-tailed tests of time-averaged difference (assuming within-patient correlation of 0.8, power = 0.9 and alpha = 0.1) to detect 20%, 30% or 50% effects of intervention on clinical and biomarkers event rates during two years of follow-up. RESULTS The change in mean lesional QSM of index hemorrhagic lesions was +7.93% per patient-year in the whole cohort. There were 5 cases (31%) of recurrent SH or lesional growth, and twice as many instances (62%) with a threshold (6%) increase in QSM. There were no instances of SH hemorrhage or lesional growth without an associated threshold increase in QSM during the same epoch. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 4 J. Magn. Reson. Imaging 2018;47:1133-1138.
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Affiliation(s)
- Hussein A Zeineddine
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Romuald Girard
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Ying Cao
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Nicholas Hobson
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Maged D Fam
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Agnieszka Stadnik
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Huan Tan
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Jingjing Shen
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Kiranj Chaudagar
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Robert Shenkar
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Richard E Thompson
- Brain Injury Outcomes unit, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nichol McBee
- Brain Injury Outcomes unit, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel Hanley
- Brain Injury Outcomes unit, Johns Hopkins University, Baltimore, Maryland, USA
| | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Gregory A Christoforidis
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A Awad
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Murthy SB, Awad I, Harnof S, Aldrich F, Harrigan M, Jallo J, Caron JL, Huang J, Camarata P, Lara LR, Dlugash R, McBee N, Eslami V, Hanley DF, Ziai WC. Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial. Neurology 2017; 89:355-362. [PMID: 28659429 DOI: 10.1212/wnl.0000000000004155] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH). METHODS Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days. RESULTS Among the 500 patients with IVH, CSF shunting was performed in 90 (18%) patients at a median of 18 (interquartile range [IQR] 13-30) days. Patient demographics and IVH characteristics were similar among patients with and without shunts. In the multivariate analysis, black race (odds ratio [OR] 1.98; 95% confidence interval [CI] 1.18-3.34), duration of EVD (OR 1.10; CI 1.05-1.15), placement of more than one EVD (OR 1.93; CI 1.13-3.31), daily drainage CSF per 10 mL (OR 1.07; CI 1.04-1.10), and intracranial pressure >30 mm Hg (OR 1.70; CI 1.09-2.88) were associated with higher odds of permanent CSF shunting. Patients who had CSF shunts had similar odds of 180-day mortality, while survivors with shunts had increased odds of poor functional outcome, compared to survivors without shunts. CONCLUSIONS Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD.
| | - Issam Awad
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Sagi Harnof
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Francois Aldrich
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Mark Harrigan
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jack Jallo
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Jean-Louis Caron
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Judy Huang
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Paul Camarata
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Lucia Rivera Lara
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Rachel Dlugash
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Nichol McBee
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Vahid Eslami
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Daniel F Hanley
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
| | - Wendy C Ziai
- From the Department of Neurology (S.B.M.) and Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M.), Weill Cornell Medicine, New York, NY; Department of Neurological Surgery (I.A.), University of Chicago Medicine, IL; Department of Neurological Surgery (S.H.), Chaim Sheba, Israel; Department of Neurological Surgery (F.A.), University of Maryland School of Medicine, Baltimore; Department of Neurological Surgery (M.H.), University of Alabama School of Medicine, Birmingham; Department of Neurological Surgery (J.J.), Thomas Jefferson University, Philadelphia, PA; Department of Neurological Surgery (J.-L.C.) and Division of Neurosciences Critical Care, Department of Neurology (L.R.L., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurological Surgery (J.H.), School of Medicine, University of Texas Health, San Antonio; Department of Neurological Surgery (P.C.), University of Kansas, Kansas City; and Division of Brain Injury Outcomes Center (R.D., N.M., V.E., D.F.H.), Johns Hopkins University, Baltimore, MD
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Adam A, Robison J, Lu J, Jose R, Badran N, Vivas-Buitrago T, Rigamonti D, Sattar A, Omoush O, Hammad M, Dawood M, Maghaslah M, Belcher T, Carson K, Hoffberger J, Jusué Torres I, Foley S, Yasar S, Thai QA, Wemmer J, Klinge P, Al-Mutawa L, Al-Ghamdi H, Carson KA, Asgari M, de Zélicourt D, Kurtcuoglu V, Garnotel S, Salmon S, Balédent O, Lokossou A, Page G, Balardy L, Czosnyka Z, Payoux P, Schmidt EA, Zitoun M, Sevestre MA, Alperin N, Baudracco I, Craven C, Matloob S, Thompson S, Haylock Vize P, Thorne L, Watkins LD, Toma AK, Bechter K, Pong AC, Jugé L, Bilston LE, Cheng S, Bradley W, Hakim F, Ramón JF, Cárdenas MF, Davidson JS, García C, González D, Bermúdez S, Useche N, Mejía JA, Mayorga P, Cruz F, Martinez C, Matiz MC, Vallejo M, Ghotme K, Soto HA, Riveros D, Buitrago A, Mora M, Murcia L, Bermudez S, Cohen D, Dasgupta D, Curtis C, Domínguez L, Remolina AJ, Grijalba MA, Whitehouse KJ, Edwards RJ, Eleftheriou A, Lundin F, Fountas KN, Kapsalaki EZ, Smisson HF, Robinson JS, Fritsch MJ, Arouk W, Garzon M, Kang M, Sandhu K, Baghawatti D, Aquilina K, James G, Thompson D, Gehlen M, Schmid Daners M, Eklund A, Malm J, Gomez D, Guerra M, Jara M, Flores M, Vío K, Moreno I, Rodríguez S, Ortega E, Rodríguez EM, McAllister JP, Guerra MM, Morales DM, Sival D, Jimenez A, Limbrick DD, Ishikawa M, Yamada S, Yamamoto K, Junkkari A, Häyrinen A, Rauramaa T, Sintonen H, Nerg O, Koivisto AM, Roine RP, Viinamäki H, Soininen H, Luikku A, Jääskeläinen JE, Leinonen V, Kehler U, Lilja-Lund O, Kockum K, Larsson EM, Riklund K, Söderström L, Hellström P, Laurell K, Kojoukhova M, Sutela A, Vanninen R, Vanha KI, Timonen M, Rummukainen J, Korhonen V, Helisalmi S, Solje E, Remes AM, Huovinen J, Paananen J, Hiltunen M, Kurki M, Martin B, Loth F, Luciano M, Luikku AJ, Hall A, Herukka SK, Mattila J, Lötjönen J, Alafuzoff I, Jurjević I, Miyajima M, Nakajima M, Murai H, Shin T, Kawaguchi D, Akiba C, Ogino I, Karagiozov K, Arai H, Reis RC, Teixeira MJ, Valêncio CG, da Vigua D, Almeida-Lopes L, Mancini MW, Pinto FCG, Maykot RH, Calia G, Tornai J, Silvestre SSS, Mendes G, Sousa V, Bezerra B, Dutra P, Modesto P, Oliveira MF, Petitto CE, Pulhorn H, Chandran A, McMahon C, Rao AS, Jumaly M, Solomon D, Moghekar A, Relkin N, Hamilton M, Katzen H, Williams M, Bach T, Zuspan S, Holubkov R, Rigamonti A, Clemens G, Sharkey P, Sanyal A, Sankey E, Rigamonti K, Naqvi S, Hung A, Schmidt E, Ory-Magne F, Gantet P, Guenego A, Januel AC, Tall P, Fabre N, Mahieu L, Cognard C, Gray L, Buttner-Ennever JA, Takagi K, Onouchi K, Thompson SD, Thorne LD, Tully HM, Wenger TL, Kukull WA, Doherty D, Dobyns WB, Moran D, Vakili S, Patel MA, Elder B, Goodwin CR, Crawford JA, Pletnikov MV, Xu J, Blitz A, Herzka DA, Guerrero-Cazares H, Quiñones-Hinojosa A, Mori S, Saavedra P, Treviño H, Maitani K, Ziai WC, Eslami V, Nekoovaght-Tak S, Dlugash R, Yenokyan G, McBee N, Hanley DF. Abstracts from Hydrocephalus 2016. Fluids Barriers CNS 2017; 14:15. [PMID: 28929972 PMCID: PMC5471936 DOI: 10.1186/s12987-017-0054-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- A Adam
- Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Robison
- Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J Lu
- Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - R Jose
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - N Badran
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - T Vivas-Buitrago
- Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - D Rigamonti
- Johns Hopkins University, Baltimore, MD, USA.,Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Johns Hopkins Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - A Sattar
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia.,Primary Care, Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - O Omoush
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia.,Primary Care, Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - M Hammad
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - M Dawood
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - M Maghaslah
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - T Belcher
- Johns Hopkins Aramco Healthcare, Ras Tanura, Saudi Arabia
| | - K Carson
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - J Hoffberger
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - I Jusué Torres
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - S Foley
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - S Yasar
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Q A Thai
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - J Wemmer
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - P Klinge
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - L Al-Mutawa
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - H Al-Ghamdi
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - K A Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M Asgari
- The Interface Group, Institute of PhysiologyUniversity of Zurich, Zurich, Switzerland
| | - D de Zélicourt
- The Interface Group, Institute of PhysiologyUniversity of Zurich, Zurich, Switzerland
| | - V Kurtcuoglu
- The Interface Group, Institute of PhysiologyUniversity of Zurich, Zurich, Switzerland.,Institute of Physiology, University of Zurich, Zurich, Switzerland.,Neuroscience Center Zurich and the Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - S Garnotel
- BioFlowImage Laboratory, University of Picardie Jules Verne, Amiens, France.,Reims Mathematics Laboratory, University of Reims Champagne-Ardenne, Reims, France.,Image Processing Laboratory, University Hospital of Amiens-Picardie, Amiens, France.,BioFlowImage Laboratory, Department of Medical Image Processing, University Hospital of Picardie Jules Verne, Amiens, France
| | - S Salmon
- Reims Mathematics Laboratory, University of Reims Champagne-Ardenne, Reims, France
| | - O Balédent
- BioFlowImage Laboratory, University of Picardie Jules Verne, Amiens, France.,Image Processing Laboratory, University Hospital of Amiens-Picardie, Amiens, France.,BioFlowImage Laboratory, Department of Medical Image Processing, University Hospital of Picardie Jules Verne, Amiens, France
| | - A Lokossou
- BioFlowImage Laboratory, Department of Medical Image Processing, University Hospital of Picardie Jules Verne, Amiens, France
| | - G Page
- BioFlowImage Laboratory, Department of Medical Image Processing, University Hospital of Picardie Jules Verne, Amiens, France
| | - L Balardy
- Department of Geriatric, University Hospital of Toulouse, Toulouse, France.,Departments of Geriatric, University Hospital of Toulouse, Toulouse, France.,Department of Geriatry, University Hospital Toulouse, Toulouse, France
| | - Z Czosnyka
- Neurosciences department, University of Cambridge, Cambridge, UK.,Brain Physics Lab, Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - P Payoux
- Department of Nuclear Medicine, University Hospital of Toulouse, Toulouse, France.,Department of Nuclear Medicine, University Hospital Toulouse, Toulouse, France.,INSER TONIC 1014, Toulouse Neuroimaging Center, Toulouse, France
| | - E A Schmidt
- UMR 1214-INSERM/UPS-TONIC Toulouse Neuro-Imaging Center, Toulouse, France.,Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France.,Department of Neurosurgery, University Hospital Toulouse, Toulouse, France
| | - M Zitoun
- BioFlowImage, University Hospital of Picardie Jules Verne, Amiens, France
| | - M A Sevestre
- BioFlowImage, University Hospital of Picardie Jules Verne, Amiens, France
| | - N Alperin
- University of Miami Health System, Miami, FL, USA
| | - I Baudracco
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - C Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - S Matloob
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - S Thompson
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - P Haylock Vize
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - L Thorne
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - L D Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - A K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.,The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Karl Bechter
- Department Psychiatry II/Bezirkskliniken, Ulm University, Günzburg, Germany
| | - A C Pong
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - L Jugé
- Neuroscience Research Australia, Randwick, Australia.,School of Medical Sciences, University of New South Wales, Kensington, Australia
| | - L E Bilston
- Neuroscience Research Australia, Randwick, Australia.,Prince of Wales Clinical School, University of New South Wales, Kensington, Australia
| | - S Cheng
- Neuroscience Research Australia, Randwick, Australia.,Department of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - W Bradley
- Department of Radiology, University of California San Diego Health System, San Diego, CA, USA
| | - F Hakim
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Neurosurgery Department, Hospital Universitario, Fundación Santafe de Bogota, Bogota, Colombia
| | - J F Ramón
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia.,Neurosurgery Department, Hospital Universitario, Fundación Santafe de Bogota, Bogota, Colombia
| | - M F Cárdenas
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - J S Davidson
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - C García
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - D González
- Department of Surgery, Section of Neurosurgery, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - S Bermúdez
- Department of Diagnostic Imaging, Section of Neuroradiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - N Useche
- Department of Diagnostic Imaging, Section of Neuroradiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - J A Mejía
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - P Mayorga
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - F Cruz
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - C Martinez
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - M C Matiz
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - M Vallejo
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - K Ghotme
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - H A Soto
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - D Riveros
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - A Buitrago
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - M Mora
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - L Murcia
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - S Bermudez
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - D Cohen
- Grupo de Hidrocefalia con Presión Normal, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - D Dasgupta
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - C Curtis
- Department of Microbiology, University College London Hospital NHS Foundation Trust, London, UK
| | - L Domínguez
- Neurosurgery Department, Cartagena University, Cartagena de Indias, Colombia
| | - A J Remolina
- Neurosurgery Department, Cartagena University, Cartagena de Indias, Colombia
| | - M A Grijalba
- Neurosurgery Department, Cartagena University, Cartagena de Indias, Colombia
| | - K J Whitehouse
- Department of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, UK
| | - R J Edwards
- Department of Paediatric Neurosurgery, Bristol Royal Hospital for Children, Bristol, UK
| | - A Eleftheriou
- Department of Neurology, University Hospital, Linköping, Sweden
| | - F Lundin
- Division of Neuroscience, Department of Clinical and Experimental Medicine (IKE), Linköping University, Linköping, Sweden
| | - K N Fountas
- Department of Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece
| | - E Z Kapsalaki
- Department of Diagnostic Radiology, School of Medicine, University of Thessaly, Larisa, Greece
| | - H F Smisson
- Department of Neurosurgery, Georgia Neurosurgical Institute, Macon, GA, USA
| | - J S Robinson
- Department of Neurosurgery, Georgia Neurosurgical Institute, Macon, GA, USA
| | - M J Fritsch
- Klinik für Neurochirurgie, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germany
| | - W Arouk
- Klinik für Neurochirurgie, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germany
| | - M Garzon
- Great Ormond Street Hospital, London, UK
| | - M Kang
- Great Ormond Street Hospital, London, UK
| | - K Sandhu
- Great Ormond Street Hospital, London, UK
| | | | - K Aquilina
- Great Ormond Street Hospital, London, UK
| | - G James
- Great Ormond Street Hospital, London, UK
| | - D Thompson
- Great Ormond Street Hospital, London, UK
| | - M Gehlen
- Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland.,Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - M Schmid Daners
- Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - A Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - J Malm
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - D Gomez
- Neurosurgery Department, Hospital Universitario, Fundación Santafe de Bogota, Bogota, Colombia
| | - M Guerra
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, UACh, Valdivia, Chile
| | - M Jara
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, UACh, Valdivia, Chile
| | - M Flores
- Laboratorio de Polímeros, Facultad de Ciencias, UACh, Valdivia, Chile
| | - K Vío
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, UACh, Valdivia, Chile
| | - I Moreno
- Laboratorio de Polímeros, Facultad de Ciencias, UACh, Valdivia, Chile
| | - S Rodríguez
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, UACh, Valdivia, Chile
| | - E Ortega
- Instituto de Neurociencias Clínicas, Facultad de Medicina, UACh, Valdivia, Chile
| | - E M Rodríguez
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, UACh, Valdivia, Chile.,Instituto de Histologia y Patologia, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - J P McAllister
- Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, MO, USA
| | - M M Guerra
- Instituto de Histologia y Patologia, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - D M Morales
- Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, MO, USA
| | - D Sival
- Department of Pediatrics Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Jimenez
- Departamento de Biología Celular, Genética y Fisiología Facultad de Ciencias, Universidad de Malaga, Malaga, Spain
| | - D D Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, MO, USA.,Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - M Ishikawa
- Rakuwa Villa Ilios, Kyoto, Japan.,Normal Pressure Hydrocephalus Center, Otowa Hospital, Kyoto, Japan
| | - S Yamada
- Normal Pressure Hydrocephalus Center, Otowa Hospital, Kyoto, Japan.,Department of Neurosurgery, Otowa Hospital, Kyoto, Japan
| | - K Yamamoto
- Department of Neurosurgery, Otowa Hospital, Kyoto, Japan
| | - A Junkkari
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - A Häyrinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - T Rauramaa
- Department of Pathology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Pathology, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Pathology, University of Eastern Finland, Kuopio, Finland
| | - H Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - O Nerg
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - A M Koivisto
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - R P Roine
- University of Eastern Finland, Kuopio Finland and Helsinki and Uusimaa Hospital DistrictGroup Administration, Helsinki, Finland
| | - H Viinamäki
- Department of Psychiatry, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - H Soininen
- Department of Neurology, University of Eastern Finland, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - A Luikku
- Neurology of NeuroCenter, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - J E Jääskeläinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Neurosurgery, Kuopio University Hospital, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - V Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Neurosurgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.,Department of Neurosurgery, Kuopio University Hospital, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - U Kehler
- Neurosurgical Department, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - O Lilja-Lund
- Department of Pharmacology and Clinical Neuroscience, Unit of Neurology, Östersund, Umeå University, Umeå, Sweden
| | - K Kockum
- Department of Pharmacology and Clinical Neuroscience, Unit of Neurology, Östersund, Umeå University, Umeå, Sweden
| | - E M Larsson
- Department of Radiology, Uppsala University, Uppsala, Sweden
| | - K Riklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - L Söderström
- Department of Pharmacology and Clinical Neuroscience, Unit of Neurology, Östersund, Umeå University, Umeå, Sweden
| | - P Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - K Laurell
- Department of Pharmacology and Clinical Neuroscience, Unit of Neurology, Östersund, Umeå University, Umeå, Sweden
| | - M Kojoukhova
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - A Sutela
- Department of Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.,Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - R Vanninen
- Department of Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - K I Vanha
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - M Timonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - J Rummukainen
- Department of Pathology, Kuopio University Hospital, Kuopio, Finland
| | - V Korhonen
- Department of Neurosurgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - S Helisalmi
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - E Solje
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - A M Remes
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - J Huovinen
- Department of Neurosurgery, Kuopio University Hospital, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - J Paananen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland.,Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - M Hiltunen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Department of Neurology, Kuopio University Hospital, Kuopio, Finland.,Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - M Kurki
- Department of Neurosurgery, Kuopio University Hospital, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Analytical and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Stanley Center for Psychiatric Research, Broad Institute for Harvard and MIT, Cambridge, MA, USA
| | - B Martin
- Biological Engineering, University of Idaho, Moscow, ID, USA
| | - F Loth
- Mechanical Engineering, University of Akron, Akron, Ohio, USA
| | - M Luciano
- Neurosurgery, Johns Hopkins University, Baltimore, MA, USA.,Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - A J Luikku
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - A Hall
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - S K Herukka
- Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - J Mattila
- VTT Technical Research Centre of Finland, Tampere, Finland.,Combinostics Ltd, Tampere, Finland
| | - J Lötjönen
- VTT Technical Research Centre of Finland, Tampere, Finland.,Combinostics Ltd, Tampere, Finland
| | - I Alafuzoff
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.,Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Department of Pathology and Cytology, Uppsala University Hospital, Uppsala, Sweden
| | - I Jurjević
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan.,Department of Pharmacology and Department of Neurology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - M Miyajima
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan.,Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - M Nakajima
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan.,Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - H Murai
- Department of Neurosurgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - T Shin
- Department of Neurosurgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - D Kawaguchi
- Department of Neurosurgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - C Akiba
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - I Ogino
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - K Karagiozov
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - H Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - R C Reis
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - M J Teixeira
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - C G Valêncio
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - D da Vigua
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - L Almeida-Lopes
- Núcleo de Pesquisa e Ensino de Fototerapia nas Ciências da Saúde (NUPEN), São Carlos, Brazil
| | - M W Mancini
- Núcleo de Pesquisa e Ensino de Fototerapia nas Ciências da Saúde (NUPEN), São Carlos, Brazil
| | - F C G Pinto
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - R H Maykot
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - G Calia
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - J Tornai
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - S S S Silvestre
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - G Mendes
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - V Sousa
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - B Bezerra
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - P Dutra
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - P Modesto
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - M F Oliveira
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - C E Petitto
- Group of Cerebral Hydrodynamics, Division of Functional Neurosurgery, Institute of Psychiatry, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - H Pulhorn
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - A Chandran
- Department of Neuroradiology, The Walton Centre, Liverpool, UK
| | - C McMahon
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - A S Rao
- The Johns Hopkins Hospital, Baltimore, MD, USA
| | - M Jumaly
- The Johns Hopkins Hospital, Baltimore, MD, USA
| | - D Solomon
- The Johns Hopkins Hospital, Baltimore, MD, USA.,Neurology, Johns Hopkins Hospital, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - A Moghekar
- The Johns Hopkins Hospital, Baltimore, MD, USA
| | - N Relkin
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - M Hamilton
- Department of Neurosurgery, University of Calgary, Alberta, Canada
| | - H Katzen
- Department of Neurology, University of Miami, Miami, FL, USA
| | - M Williams
- Department of Neurosurgery, Washington University, Seattle, WA, USA
| | - T Bach
- Utah Data Collection Center (DCC), University of Utah, Salt Lake City, UT, USA
| | - S Zuspan
- Utah Data Collection Center (DCC), University of Utah, Salt Lake City, UT, USA
| | - R Holubkov
- Utah Data Collection Center (DCC), University of Utah, Salt Lake City, UT, USA
| | | | - G Clemens
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - P Sharkey
- School of Business, Loyola University Maryland, Baltimore, MD, USA
| | - A Sanyal
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - E Sankey
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - K Rigamonti
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - S Naqvi
- Primary Care, Johns Hopkins Aramco Healthcare, Abqaiq, Saudi Arabia
| | - A Hung
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - E Schmidt
- Department of Neurosurgery, University Hospital Toulouse, Toulouse, France
| | - F Ory-Magne
- Department of Neurology, University Hospital Toulouse, Toulouse, France.,INSER TONIC 1014, Toulouse Neuroimaging Center, Toulouse, France
| | - P Gantet
- Department of Nuclear Medicine, University Hospital Toulouse, Toulouse, France
| | - A Guenego
- Department of Neurosurgery, University Hospital Toulouse, Toulouse, France.,Department of Neuroradiology, University Hospital Toulouse, Toulouse, France
| | - A C Januel
- Department of Neuroradiology, University Hospital Toulouse, Toulouse, France
| | - P Tall
- Department of Neuroradiology, University Hospital Toulouse, Toulouse, France
| | - N Fabre
- Department of Neurology, University Hospital Toulouse, Toulouse, France
| | - L Mahieu
- Department of Ophtalmology, University Hospital Toulouse, Toulouse, France
| | - C Cognard
- Department of Neuroradiology, University Hospital Toulouse, Toulouse, France
| | - L Gray
- Department of Physiology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | | | - K Takagi
- Normal Pressure Hydrocephalus Center, Kashiwa-Tanaka Hospital, Kashiwa, Japan
| | - K Onouchi
- Department of Neurology, Kashiwa-Tanaka Hospital, Kashiwa, Japan
| | - S D Thompson
- The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - L D Thorne
- The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - H M Tully
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - T L Wenger
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - W A Kukull
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - D Doherty
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - W B Dobyns
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - D Moran
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - S Vakili
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - M A Patel
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - B Elder
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - C R Goodwin
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J A Crawford
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - M V Pletnikov
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J Xu
- F. M. Kirby Research Center for Functional Brain Imaging at the Kennedy Krieger Institute, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - A Blitz
- Department of Radiology and Radiological Science, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - D A Herzka
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - H Guerrero-Cazares
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - A Quiñones-Hinojosa
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - S Mori
- Department of Radiology-Magnetic Resonance Research, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - P Saavedra
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - H Treviño
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - K Maitani
- Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Tohoku University School of Medicine, Sendai, Japan
| | - W C Ziai
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - V Eslami
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Nekoovaght-Tak
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Dlugash
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Yenokyan
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - N McBee
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D F Hanley
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, Dawson J, Gandhi D, Ullman N, Mould WA, Mayo SW, Mendelow AD, Gregson B, Butcher K, Vespa P, Wright DW, Kase CS, Carhuapoma JR, Keyl PM, Diener-West M, Muschelli J, Betz JF, Thompson CB, Sugar EA, Yenokyan G, Janis S, John S, Harnof S, Lopez GA, Aldrich EF, Harrigan MR, Ansari S, Jallo J, Caron JL, LeDoux D, Adeoye O, Zuccarello M, Adams HP, Rosenblum M, Thompson RE, Awad IA. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389:603-611. [PMID: 28081952 PMCID: PMC6108339 DOI: 10.1016/s0140-6736(16)32410-2] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [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: 07/01/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Daniel F Hanley
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA.
| | - Karen Lane
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Nichol McBee
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Wendy Ziai
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Stanley Tuhrim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Natalie Ullman
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | | | | | | | | | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | | | | | - J Ricardo Carhuapoma
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Penelope M Keyl
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Marie Diener-West
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - John Muschelli
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Joshua F Betz
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Carol B Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Scott Janis
- National Institutes of Health, National institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | | | - Sagi Harnof
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | | | | | | | | | - Jack Jallo
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - David LeDoux
- North Shore Long Island Jewish Medical Center, Manhasset, NY, USA
| | | | | | | | - Michael Rosenblum
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Richard E Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
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42
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Koffman L, Hanley D, Anderson C, Mendelow D, Gregson B, Wang X, Lane K, McBee N, Dlugash R, Awad I, Ziai W. Abstract 148: Evaluation of Sex, Racial and Geographic Demographics and Outcomes in Clinical Trials of Spontaneous Intracerebral Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
As large clinical trials for spontaneous intracerebral hemorrhage (ICH) increasingly influence management, recruitment of diverse populations must be ensured to fully understand the disease process and benefit of interventions to the general public. There is little data on sex, race and outcomes in ICH trials. We hypothesize that women and geographic minorities are underrepresented in ICH clinical trials and that there exist population specific differences in mortality, functional outcomes and response to interventions.
Methods:
Pooled analysis of 5456 subjects from the following clinical trials: VISTA (985), INTERACT I (404) and II (2829), STICH II (597), MISTIE II (141) and CLEAR III (500). Patients were grouped by sex, race, and geographic location. Modified Rankin Scale [mRS] was obtained at 30 days and 3 months.
Results:
More men than women participated in ICH trials (61.9% vs. 38.1%); women were older and more likely to have hypertension; men had more coronary artery disease. Women presented with lower Glasgow Coma scale, higher ICH score and more intraventricular hemorrhage. Day 90 mortality was 13.9% in women and 16.6 % in men (p=0.01); 90 day poor outcome (mRS 3-5) was 57.2% in women and 51.0% in men (p<0.001). Only mortality was significantly different between sexes after adjustment for ICH score. Race representation varied in these clinical trials: 1.5% Hispanic; 6.6% black; 14% Arabic; 31% white and 43.4% Asian. Day 90 mortality and mRS 3-5 were highest in Hispanics (22.1%, 78.3%, respectively) and lowest in Asians (9.5%, 43.8%). Hispanics had higher ICH score, but blacks and Hispanics had lower day 90 mortality compared to whites in adjusted models. Asians had both lower mortality and less day 90 mRS 3-5 vs. whites while Arabics and blacks were more likely to have day 90 mRS 3-5. Study interventions were well balanced by sex and race.
Conclusions:
Sex and race representation in ICH clinical trials only partially equate to current understanding of epidemiology of ICH. There is a lack of trial evidence from Africa and South America and under-representation of women, Hispanics and blacks. Despite higher ICH severity, Hispanics had lower adjusted mortality risk while males had higher risk and Arabics and blacks had worse adjusted poor outcomes.
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Affiliation(s)
| | | | | | | | | | - Xia Wang
- The George Institute for Global Health, Camperdown, Australia
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43
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Mould WA, Muschelli J, McBee N, Lane K, Zuccarello M, Awad I, Hanley D. Abstract WP353: Bleeding Following Removal of Intracerebral Catheters in MISTIE III. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Minimally invasive surgery plus alteplase has been shown to effectively reduce the volume of intracerebral hemorrhage in patients with supratentorial bleeds. Removal of these catheters is a unique timepoint when bleeding may restart due to mechanical forces and/or the presence of alteplase/plasmin in the brain. We hypothesized that surgically-treated patients in the MISTIE III trial who had increased bleeding post catheter removal would have shorter periods of time between last dose and catheter removal and be less likely to have lobar ICH.
Methods:
MISTIE III is a prospective, randomized trial testing the efficacy of minimally invasive surgery plus alteplase for hematoma removal compared to medical management. We analyzed 107 surgically-treated patients. Semi-automated threshold based segmentation of the ICH volumes for all time points were performed using OsiriX.
Results:
Of the 107 surgical patients, 16 experienced an increase in ICH volume >10% between T1, the scan taken 24 hours prior to cath removal, and T2, the scan taken 24 hours post catheter removal. Mean percent difference between T1 and T2 was 37.5% for those that expanded versus those that did not, -17.4% (p<0.001) with an absolute difference in ICH volume of 3.0 cc and -2.2 cc (p<0.001). The mean residual volume at T2 for both groups was similar at 12.84 cc and 12.71 cc, respectively (p=0.96). Time from last dose to catheter removal in days was 1.27 for those that expanded and 1.44 for those that did not (p=0.09). Furthermore, 14/16 (87.5%) patients with expansion had ICH’s located in deep structures compared to 55/91 (60.4%) of patients that did not expand (p<0.01).
Conclusion:
Overall, incidence of bleeding following ICH catheter removal in MISTIE III was low. When bleeding was seen, it was more often found in patients with deep ICH locations and whose catheters were removed sooner after the last dose of alteplase.
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Affiliation(s)
| | - John Muschelli
- Biostatistics, Johns Hopkins Sch of Public Health, Baltimore, MD
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44
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Jeon JE, Mighty J, Lane K, McBee N, Majkowski R, Mayo S, Hanley D. Participation of a coordinating center pharmacy in a multicenter international study. Am J Health Syst Pharm 2016; 73:1859-1868. [PMID: 27821398 PMCID: PMC6188656 DOI: 10.2146/ajhp150849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The activities of a coordinating center pharmacy (CCP) supporting a multicenter, international clinical trial are described. SUMMARY Serving in a research support role comparable to that of a commercial clinical trial supply company, a CCP within the Johns Hopkins Hospital Investigational Drug Service (JHH IDS) uses its management expertise and infrastructure to support multicenter trials, such as the recently completed Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage, Phase III (CLEAR III) trial. The role of the CCP staff in supporting the CLEAR III trial was overall investigational product (IP) management through coordination of IP-related operations to ensure high-quality care for study participants at study sites in the United States and abroad. For the CLEAR III trial, the CCP coordinated IP supply activities; provided education to site pharmacists; developed study-specific documents, including pharmacy manuals; communicated with trial stakeholders, including third-party IP distributors; monitored treatment assignments; and performed quality assurance monitoring to ensure compliance with institutional, state, federal, and international regulations regarding IP procurement and storage. Acting as a CCP for a multicenter international study poses a number of operational challenges while providing opportunities for the CCP to contribute to research of global importance and enrich the skill sets of its personnel. CONCLUSION The development and implementation of the CCP at JHH IDS for the CLEAR III trial included several responsibilities, such as IP supply management, communication, and database, regulatory, and finance management.
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Affiliation(s)
| | - Janet Mighty
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ryan Majkowski
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Daniel Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD
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45
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Vespa P, Hanley D, Betz J, Hoffer A, Engh J, Carter R, Nakaji P, Ogilvy C, Jallo J, Selman W, Bistran-Hall A, Lane K, McBee N, Saver J, Thompson RE, Martin N. ICES (Intraoperative Stereotactic Computed Tomography-Guided Endoscopic Surgery) for Brain Hemorrhage: A Multicenter Randomized Controlled Trial. Stroke 2016; 47:2749-2755. [PMID: 27758940 DOI: 10.1161/strokeaha.116.013837] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [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: 04/21/2016] [Accepted: 09/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is a devastating disease without a proven therapy to improve long-term outcome. Considerable controversy about the role of surgery remains. Minimally invasive endoscopic surgery for ICH offers the potential of improved neurological outcome. METHODS We tested the hypothesis that intraoperative computerized tomographic image-guided endoscopic surgery is safe and effectively removes the majority of the hematoma rapidly. A prospective randomized controlled study was performed on 20 subjects (14 surgical and 4 medical) with primary ICH of >20 mL volume within 48 hours of ICH onset. We prospectively used a contemporaneous medical control cohort (n=36) from the MISTIE trial (Minimally Invasive Surgery and r-tPA for ICH Evacuation). We evaluated surgical safety and neurological outcomes at 6 months and 1 year. RESULTS The intraoperative computerized tomographic image-guided endoscopic surgery procedure resulted in immediate reduction of hemorrhagic volume by 68±21.6% (interquartile range 59-84.5) within 29 hours of hemorrhage onset. Surgery was successfully completed in all cases, with a mean operative time of 1.9 hours (interquartile range 1.5-2.2 hours). One surgically related bleed occurred peri-operatively, but no patient met surgical safety stopping threshold end points for intraoperative hemorrhage, infection, or death. The surgical intervention group had a greater percentage of patients with good neurological outcome (modified Rankin scale score 0-3) at 180 and 365 days as compared with medical control subjects (42.9% versus 23.7%; P=0.19). CONCLUSIONS Early computerized tomographic image-guided endoscopic surgery is a safe and effective method to remove acute intracerebral hematomas, with a potential to enhance neurological recovery. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00224770.
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Affiliation(s)
- Paul Vespa
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.).
| | - Daniel Hanley
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Joshua Betz
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Alan Hoffer
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Johnathan Engh
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Robert Carter
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Peter Nakaji
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Chris Ogilvy
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Jack Jallo
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Warren Selman
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Amanda Bistran-Hall
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Karen Lane
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Nichol McBee
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Jeffery Saver
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Richard E Thompson
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
| | - Neil Martin
- From the Departments of Neurosurgery and Neurology, David Geffen School of Medicine at University of California, Los Angeles (P.V., J.S., N. Martin); Department of Neurology, Johns Hopkins University, Baltimore, MD (D.H., J.B., A.B.-H., K.L., N. McBee, R.E.T.); Department of Neurosurgery, Case Western University (A.H., W.S.); Department of Neurosurgery, University of Pittsburgh, PA (J.E., P.N.); Department of Neurosurgery, University of California, San Diego (R.C.); Department of Neurosurgery, Harvard University, Massachusetts General Hospital, Boston (C.O.); and Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (J.J.)
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Ziai WC, Siddiqui AA, Ullman N, Herrick DB, Yenokyan G, McBee N, Lane K, Hanley DF. Early Therapy Intensity Level (TIL) Predicts Mortality in Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2016; 23:188-97. [PMID: 26025213 DOI: 10.1007/s12028-015-0150-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Outcome from spontaneous intracerebral hemorrhage (sICH) may depend on patient-care variability. We developed as ICH-specific therapy intensity level (TIL) metric using evidence-based elements in a high severity sICH cohort. METHODS This is a cohort study of 170 patients with sICH and any intraventricular hemorrhage treated in 2 academic neuroICUs. Pre-defined quality indicators were identified based on current guidelines, scientific evidence, and likelihood of care documentation in first 72 h of hospital admission. We assessed performance on each indicator and association with discharge mortality. Significant indicators were aggregated to develop a TIL score. The predictive validity of the best fit TIL score was tested with threefold cross-validation of multivariate logistic regression models of in-hospital survival and good outcome (modified Rankin score 0-3). RESULTS Median ICH score was 3; discharge mortality was 51.2%. Five/19 tested variables were significantly associated with lower discharge mortality: no DNR/withdrawal of treatment within 24 h of admission, target glucose within 4 h of high glucose, no recurrent hyperpyrexia, clinical reversal of herniation/intracranial pressure >20 mmHg within 60 min of detection, and reversal of INR (<1.4) within 2 h of first elevation. One point was given for each or if not applicable. Median TIL score was significantly higher in survivors versus non-survivors (5[1] vs. 3[1]; P < 0.001). A 4-point aggregated TIL score was most predictive of discharge survival (area under receiving operating characteristic curve 0.85, 95% CI 0.80-0.90) and good outcome (AUC 0.84) and was an independent predictor of both (survival: OR 7.10; 95% CI 3.57-14.11; P < 0.001; good outcome: OR 3.10; 95% CI 1.06-8.79; P < 0.001). CONCLUSION A simplified TIL score using evidenced-based patient-care parameters within first 3 days of admission after sICH was significantly associated with early mortality and good outcome. The next step is prospective validation of the simplified TIL score in a large clinical trial.
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Affiliation(s)
- Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 Wolf Street/Phipps 455, Baltimore, MD, 21287, USA,
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Mould WA, Müller A, Ziai W, McBee N, Lane K, Awad I, Hanley D. Abstract 216: Incidence and Severity of Catheter Tract Hemorrhage and EVD Placement Accuracy in the CLEAR-III Trial. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
CLEAR III trial is a multicenter, double-blind, randomized trial comparing external ventricular drainage (EVD) plus intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD plus placebo for treatment of IVH in patients with obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. New hemorrhage along the catheter tract (CTH) associated with EVD placement is known to occur but magnitude and significance of CTH is not well understood. We investigated incidence and severity risk factors for CTH in the CLEAR-III trial.
Methods:
Retrospective analysis of 4698 CT scans from EVD placement through EVD removal in all 500 patients enrolled in CLEAR III. CTH was characterized using an ordinal severity scale and quantified using both manual and threshold based segmentation to calculate a volume. EVD location was graded using a modification of the Kakarla scale for each CT scan. Demographic and clinical data were assessed for pre-specified associations.
Results:
Incidence of CTH was 44.8% (224/500) which included 318 CTHs (single:160 patients; two:51; three:8; four:8). CTH occurred within first 24 hours of placement in 102 (32%), after 24 hours in 132 (41%), after EVD repositioning/manipulation in 19 (6%), after EVD replacement in 15 (5%), and after EVD removal in 50 (16%). The mean CTH volume was 2.01 ml with a range of 0.1 ml - 57.95 ml. CTH volume was not associated with EVD accuracy, nor number of doses given but increased significantly with the number of catheters placed per patient (p<0.001). Furthermore, Grade 2 or 3 CTH (larger than trace, with or without edema) occurred in 31.8% and were significantly associated with lower platelet count (p=0.047) while grade 2/3 CTH on initial placement were significantly associated with pre-admission antiplatelet agent use (p=0.02).
Conclusion:
Our data suggest that EVD tract hemorrhages can occur at any point within the acute treatment period with varying severity. Hematologic factors, especially history of antiplatelet agent use may increase risk of larger potentially symptomatic CTH.
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Ziai W, Bhuiyan M, McBee N, Dlugash R, Sheth K, Ram M, Mayo S, Thompson C, Lane K, Awad I, Hanley DF. Abstract WMP86: Evaluation of Cerebrospinal Fluid Dynamics and External Ventricular Drain Management in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial (CLEAR III). Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wmp86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Acute obstructive hydrocephalus secondary to spontaneous intracerebral/intraventricular hemorrhage (ICH/IVH) requires early cerebrospinal fluid (CSF) drainage to reduce intracranial pressure (ICP). Extensive CSF drainage may reduce IVH clot burden. We characterize CSF dynamics, strategies and impact on end of treatment (EOT) IVH volume (72 hours post randomization [Rand]) in the CLEAR III trial.
Methods:
Prospective analysis of CSF output in all 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. CSF output was recorded every 4 hours until 7 days post Rand, and compared by clinical and radiological variables.
Results:
Daily median CSF output in the first week was 188cc (IQR: 125, 252). Maximum daily EVD drip settings were <10mmHg in 27.8%, =10 in 44.1% and >10 in 28.1%. Independent predictors of higher daily CSF output after adjustment for initial IVH volume (p=0.04) were lower drip setting (p<0.001), lower age (p<0.001), male sex (p=0.03), dual EVD (p=0.005), CSF protein (p<0.001) and ICP>20mmHg (P=0.007). Both EOT IVH volume and change in IVH volume (ChgIVH) (over 1
st
week) were independently associated with total CSF output (P=0.004/<0.001, respectively), and initial IVH volume (P<0.001/<0.001)). Early opening of 3
rd
and 4
th
ventricle (P=0.03) was associated with lower EOT volumes, while CSF protein (P=0.02), and side of EVD ipsilateral to largest IVH (P=0.04) were associated with ChgIVH. Shunting for hydrocephalus was performed in 18.6% over 1 year follow-up and was associated with higher total CSF output over first week (P<0.001).
Conclusions:
CSF circulation in severe IVH can be assessed by CSF output which is associated with EVD drip management and other clinical variables. EOT IVH volume and IVH volume reduction are important surrogate endpoints which are related to CSF dynamics. VP shunt requirement in spontaneous IVH is associated with early CSF output levels. These results permit future correlation of CSF output with treatment rendered (thrombolysis versus placebo) with upcoming unblinding of the trial.
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Affiliation(s)
- Wendy Ziai
- Johns Hopkins Univ Neuro Criti, Baltimore, MD
| | | | - Nichol McBee
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | | | | | - Malathi Ram
- Biostatistics, Johns Hopkins Univ Sch of Public Health, Baltimore, MD
| | - Steven Mayo
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Carol Thompson
- Biostatistics, Johns Hopkins Univ Sch of Public Health, Baltimore, MD
| | - Karen Lane
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | - Daniel F Hanley
- Neurology, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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Shah JN, Murthy SB, McBee N, Dlugash R, Ram M, Lane K, Awad I, Hanley DF, Ziai WC. Abstract TP376: Infections in Patients With Spontaneous Intraventricular Hemorrhage- Results From the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III Trial. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intraventricular hemorrhage (IVH) occurs in about 40% of patients with intracerebral hemorrhage (ICH) and is associated with higher mortality and worse outcomes than ICH patients without IVH. Infections are common in ICH patients but data in IVH patients are limited.
Methods:
Prospective analysis of adjudicated adverse event infection reporting during first 180 days in 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing external ventricular drain (EVD) + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Primary outcome measures were 90-day and 180-day mortality. Secondary outcome measures were hospital length of stay (LOS). We constructed binary logistic and linear regression models for multivariable analysis.
Results:
Infection was reported in 269 patients (53.8%). Pneumonia was the most common infection (33%), followed by UTI (16%), and bacterial ventriculitis (4.4%). Overall 180-day mortality was 20%. Patients with infection were more likely to have older age (p=0.012), lower admission GCS (p=0.007), higher ICH volume (8.8 vs 6.7ml, p=0.001), and higher ICH+IVH volume (37.7 vs 31.7 ml, p=0.002). In the regression model, IVH volume was associated with higher odds of 90-day or 180-day mortality, but presence of any infection was not a significant predictor of mortality. Infection was however associated with longer length of stay (26 vs 22 days, p<0.001). Subgroup analysis of individual infections, showed only bacterial ventriculitis to be associated with 90-day (OR: 3.84, CI: 1.36-10.82), and 180-day mortality (OR: 2.9, CI: 1.05-8.06), while pneumonia and UTI were not.
Conclusion:
Patients with IVH have a high incidence of infections, which is associated with longer hospitalization but does not appear to influence mortality. Of the infections, bacterial ventriculitis is a significant predictor of mortality in our 7-factor model. IVH volume did not predict infections but predicted mortality.These results form a basis for future correlation of infectious complications with treatment rendered (thrombolysis versus placebo), with upcoming unblinding of the trial.
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Affiliation(s)
- Jharna N Shah
- Neurosciences Critical Care Div, Johns Hopkins Univ, Baltimore, MD
| | | | - Nichol McBee
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Rachel Dlugash
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Malathi Ram
- International Health/Global Disease Epidemiology and Control, Johns Hopkins Univ, Baltimore, MD
| | - Karen Lane
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | - Daniel F Hanley
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Wendy C Ziai
- Neurosciences Critical Care Div, Johns Hopkins Univ, Baltimore, MD
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Shah JN, Murthy SB, McBee N, Dlugash R, Ram M, Lane K, Awad I, Hanley DF, Ziai W. Abstract 217: Venous Thromboembolism in Patients With Spontaneous Intraventricular Hemorrhage- Results From the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III Trial. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intraventricular hemorrhage (IVH) occurs in about 40% of patients with intracerebral hemorrhage (ICH) and is associated with higher mortality and worse outcomes than ICH patients without IVH. Venous thromboembolism (VTE) is common in ICH patients but data in IVH patients are limited.
Methods:
Prospective analysis of adjudicated adverse event reporting of VTE (deep venous thrombosis (DVT) and pulmonary embolism (PE)) during first 180 days in 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing external ventricular drain (EVD) + intraventricular recombinant tissue plasminogen activator (rtPA) vs EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Outcome measures were 90-day and 180-day mortality, ICU and hospital length of stay (LOS), catheter tract hemorrhage as well as predictors of VTE.
Results:
VTE was reported in 63 patients (13%); 46 (9%), 11 (2%) and 6 (1%) patients had DVT, PE or both, respectively. VTE occurred between 4 and 209 days from ICH onset. VTE pharmacologic prophylaxis was initiated in 404 (81%) patients, at median of 4 days [range:1-48] from ICH onset. Unfractionated and low molecular weight heparin were used in 71% and 29% patients, respectively. These patients had similar rates of VTE but showed a trend towards higher catheter tract hemorrhages (25 vs 15%, p=0.056) as compared to those who did not receive VTE prophylaxis. Patients who developed VTE had similar 90-d and 180-d mortality and ICU LOS but had prolonged hospital LOS (p=0.012) as compared to those who did not develop VTE. On multivariable analysis, ICH volume was a significant predictor of development of VTE (OR 1.04, 95% CI: 1.01-1.07, p=0.024).
Conclusions:
The association of IVH with VTE is important but complex, in spite of consideration of early VTE prophylaxis. There was trend towards higher catheter tract hemorrhages in patients receiving VTE prophylaxis. ICH volume was a significant predictor of VTE development. However, mortality and ICU LOS were not affected by VTE development. These results form a basis for future correlation of VTE complications with treatment rendered (thrombolysis versus placebo), with upcoming unblinding of the trial.
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Affiliation(s)
- Jharna N Shah
- Neurosciences Critical Care Div, Johns Hopkins Univ, Baltimore, MD
| | | | - Nichol McBee
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Rachel Dlugash
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Malathi Ram
- International Health/Global disease epidemiology and control, Johns Hopkins Univ, Baltimore, MD
| | - Karen Lane
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Issam Awad
- Neurosurgery, Univ of Chicago, Chicago, IL
| | - Daniel F Hanley
- Brain Injury Outcomes Div, Johns Hopkins Univ, Baltimore, MD
| | - Wendy Ziai
- Neurosciences Critical Care Div, Johns Hopkins Univ, Baltimore, MD
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