1
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van den Berg SA, Uniken Venema SM, LeCouffe NE, Postma AA, Lycklama à Nijeholt GJ, Rinkel LA, Treurniet KM, Kappelhof M, Bruggeman AE, van Kranendonk KR, Majoie CBLM, Dippel DWJ, van der Worp HB, Coutinho JM, Nederkoorn PJ, Roos YBWEM. Admission blood pressure and clinical outcomes in patients with acute ischaemic stroke treated with intravenous alteplase and endovascular treatment versus endovascular treatment alone: A MR CLEAN-NO IV substudy. Eur Stroke J 2023; 8:647-654. [PMID: 37641554 PMCID: PMC10472956 DOI: 10.1177/23969873231173274] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION High systolic blood pressure (SBP) is associated with poor functional outcome. We analysed whether the association of SBP with outcomes after endovascular treatment (EVT) is modified by prior intravenous thrombolysis (IVT). PATIENTS AND METHODS This was a post-hoc analysis of MR CLEAN-NO IV, a randomised trial of IVT with alteplase followed by EVT versus EVT alone, within 4.5 h from stroke onset. SBP was recorded on hospital admission. The primary outcome was 90-day modified Rankin Scale (mRS) score and secondary outcomes included symptomatic intracranial haemorrhage (sICH) and successful reperfusion (eTICI 2b-3), analysed with (ordinal) logistic regression. Estimates were calculated per 10 mmHg change in SBP. We assessed whether IVT modified the associations of SBP with these outcomes using multiplicative interaction terms. RESULTS Of 539 randomised patients, 266 received IVT. The association of SBP with mRS score was J-shaped, with an inflection point at 150 mmHg. Using 150 mmHg as a reference point, SBPs higher than 150 mmHg were associated with poor functional outcome (acOR: 1.23, 95% CI: 1.09-1.38), but lower SBPs were not (acOR: 1.14, 95% CI: 0.99-1.30). Higher SBP was not associated with the risk of sICH (aOR: 1.09, 95% CI: 0.93-1.27) nor with the probability of successful reperfusion (aOR: 1.00, 95% CI: 0.91-1.10). Our main result was that we found no effect modification by IVT (p-values for interaction, mRS = 0.94; sICH = 0.26; successful reperfusion = 0.58). DISCUSSION AND CONCLUSION There was no effect modification of IVT with SBP for any of the clinical outcomes. Therefore, the level of SBP (if ⩽185/110 mmHg) should not guide IVT decisions in patients otherwise eligible for both IVT and EVT within the 4.5-h time window. TRIAL REGISTRATION ISRCTN80619088, https://www.isrctn.com/ISRCTN80619088.
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Affiliation(s)
- Sophie A van den Berg
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Kilian M Treurniet
- Department of Radiology, Haaglanden Medical Center, Den Haag, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Agnetha E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Roos YBWEM, Uyttenboogaart M, Buskens E. Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke. Eur Stroke J 2023; 8:638-646. [PMID: 37641549 PMCID: PMC10472948 DOI: 10.1177/23969873231174943] [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] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. METHODS A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. RESULTS Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. CONCLUSIONS Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Management and Economic, Hanoi University of Pharmacy, Vietnam
| | - Maarten MH Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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3
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Kauw F, Bernsen MLE, Dankbaar JW, de Jong HWAM, Kappelle LJ, Velthuis BK, van der Worp HB, van der Lugt A, Roos YBWEM, Yo LSF, van Walderveen MAA, Hofmeijer J, Bennink E. Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke. Int J Stroke 2023; 18:187-192. [PMID: 35373655 PMCID: PMC9896253 DOI: 10.1177/17474930221094693] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a potential predictor of malignant edema formation in patients with acute ischemic stroke. AIMS We aimed to evaluate the added value of the CSF/ICV ratio in a model to predict malignant edema formation in patients who underwent endovascular treatment. METHODS We included patients from the MR CLEAN Registry, a prospective national multicenter registry of patients who were treated with endovascular treatment between 2014 and 2017 because of acute ischemic stroke caused by large vessel occlusion. The CSF/ICV ratio was automatically measured on baseline thin-slice noncontrast CT. The primary outcome was the occurrence of malignant edema based on clinical and imaging features. The basic model included the following predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, occlusion of the internal carotid artery, collateral score, time between symptom onset and groin puncture, and unsuccessful reperfusion. The extended model included the basic model and the CSF/ICV ratio. The performance of the basic and the extended model was compared with the likelihood ratio test. RESULTS Malignant edema occurred in 40 (6%) of 683 patients. In the extended model, a lower CSF/ICV ratio was associated with the occurrence of malignant edema (odds ratio (OR) per percentage point, 1.2; 95% confidence interval (CI) 1.1-1.3, p < 0.001). Age lost predictive value for malignant edema in the extended model (OR 1.1; 95% CI 0.9-1.5, p = 0.372). The performance of the extended model was higher than that of the basic model (p < 0.001). CONCLUSIONS Adding the CSF/ICV ratio improves a multimodal prediction model for the occurrence of malignant edema after endovascular treatment.
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Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,Frans Kauw, Department of Radiology, University Medical Center Utrecht, Utrecht University, Room Q.01.4.46, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
| | | | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hugo WAM de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lonneke SF Yo
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,Image Sciences Institute, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Olthuis SGH, Hinsenveld WH, Pinckaers FME, Amini M, Lingsma HF, Staals J, HCML Schreuder T, Schonewille WJ, Yo LSF, BWEM Roos Y, Postma AA, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ, de Ridder IR. Association between type of intervention center and outcomes after endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry. Eur Stroke J 2022; 8:224-230. [PMID: 37021181 PMCID: PMC10069206 DOI: 10.1177/23969873221145771] [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] [Received: 10/13/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) is performed in intervention centers that provide the full range of neuro(endo)vascular care (level 1) and centers that only perform EVT for AIS (level 2). We compared outcomes between these center types and assessed whether differences in outcomes could be explained by center volume (CV). Patients and methods: We analyzed patients included in the MR CLEAN Registry (2014–2018), a registry of all EVT-treated patients in the Netherlands. Our primary outcome was the shift on the modified Rankin scale (mRS) after 90 days (ordinal regression). Secondary outcomes were the NIHSS 24–48 h post-EVT, door-to-groin time (DTGT), procedure time (linear regression), and recanalization (binary logistic regression). We compared outcomes between level 1 and 2 centers using multilevel regression models, with center as random intercept. We adjusted for relevant baseline factors, and in case of observed differences, we additionally adjusted for CV. Results: Of the 5144 patients 62% were treated in level 1 centers. We observed no significant differences between center types in mRS (adjusted(a)cOR: 0.79, 95% CI: 0.40 to 1.54), NIHSS (aβ: 0.31, 95% CI: −0.52 to 1.14), procedure duration (aβ: 0.88, 95% CI: −5.21 to 6.97), or DTGT (aβ: 4.24, 95% CI: −7.09 to 15.57). The probability for recanalization was higher in level 1 centers compared to level 2 centers (aOR 1.60, 95% CI: 1.10 to 2.33), and this difference probably depended on CV. Conclusions: We found no significant differences, that were independent of CV, in the outcomes of EVT for AIS between level 1 and level 2 intervention centers.
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Affiliation(s)
- Susanne GH Olthuis
- Department of Neurology, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Wouter H Hinsenveld
- Department of Neurology, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Florentina ME Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Marzyeh Amini
- Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | | | | | - Lonneke SF Yo
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre and School for Mental Health and Sciences (MheNS), Maastricht, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Centre and School for Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
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5
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Rinkel LA, Beemsterboer CFP, Groeneveld NS, Lobé NHJ, Boekholdt SM, Bouma BJ, Muller FF, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Cardiac thrombi detected by CT in patients with acute ischemic stroke: A substudy of Mind the Heart. Eur Stroke J 2022; 8:168-174. [PMID: 37021199 PMCID: PMC10069221 DOI: 10.1177/23969873221130838] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Cardiac thrombi are a major risk factor for ischemic stroke, but are rarely diagnosed in the acute phase. We examined characteristics and functional outcome of patients with ischemic stroke and a concomitant cardiac thrombus detected on cardiac CT performed in the acute phase. Patients and Methods: We used data from “Mind the Heart,” a prospective cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during their acute stroke imaging protocol. We compared characteristics, functional outcome (modified Rankin scale) and stroke recurrence rate at 90 days of patients with a cardiac thrombus on CT (defined as filling defect <100 Hounsfield Units) to those without a cardiac thrombus. Results: Among 452 included patients, cardiac CT detected 41 thrombi in 38 (8%) patients. Thrombi were most often located in the left atrial appendage (31/38 [82%]). Patients with a cardiac thrombus more frequently had intracranial occlusions in multiple vascular territories (5% vs 0.5%, p = 0.04) and a higher baseline NIHSS score (17 [IQR 6–22] vs 5 [IQR 2–3], p < 0.001) compared to patients without a cardiac thrombus. In 13/38 (34%) patients with a cardiac thrombus, no atrial fibrillation was detected. A cardiac thrombus was associated with worse functional outcome (adjusted common odds ratio 3.18 95%CI 1.68–6.00). Recurrence rate was not significantly different (8% vs 4%, aOR 1.50 (0.39–5.82). Discussion and Conclusion: Cardiac CT detected a cardiac thrombus in one in every 12 patients with acute ischemic stroke, and these patients had more severe deficits, multivessel occlusions, and a worse functional outcome.
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Affiliation(s)
- Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Chiel FP Beemsterboer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick HJ Lobé
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fenna F Muller
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo FM Beenen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Departments of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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6
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Luijten SPR, Compagne KCJ, van Es ACGM, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ, van Zwam WH, Dippel DWJ, Wolters FJ, van der Lugt A, Bos D. Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial. Int J Stroke 2021; 17:17474930211054964. [PMID: 34711105 PMCID: PMC9483187 DOI: 10.1177/17474930211054964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion. METHODS We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation. RESULTS We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74] in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile). CONCLUSION Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.
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Affiliation(s)
- Sven PR Luijten
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kars CJ Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan CGM van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Frank J Wolters
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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7
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Affiliation(s)
- J A Smaal
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - I R de Ridder
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A Heshmatollah
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Dwj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - C B Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - S Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - M Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Bcv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - K W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - A M Demchuck
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - A Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain
| | - T G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - P J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - P White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - J L Saver
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Y B Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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8
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Koster GT, Nguyen TTM, van Zwet EW, Garcia BL, Rowling HR, Bosch J, Schonewille WJ, Velthuis BK, van den Wijngaard IR, den Hertog HM, Roos YBWEM, van Walderveen MAA, Wermer MJH, Kruyt ND. Clinical prediction of thrombectomy eligibility: A systematic review and 4-item decision tree. Int J Stroke 2019; 14:530-539. [PMID: 30209989 PMCID: PMC6710617 DOI: 10.1177/1747493018801225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 04/11/2018] [Accepted: 06/25/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND A clinical large anterior vessel occlusion (LAVO)-prediction scale could reduce treatment delays by allocating intra-arterial thrombectomy (IAT)-eligible patients directly to a comprehensive stroke center. AIM To subtract, validate and compare existing LAVO-prediction scales, and develop a straightforward decision support tool to assess IAT-eligibility. METHODS We performed a systematic literature search to identify LAVO-prediction scales. Performance was compared in a prospective, multicenter validation cohort of the Dutch acute Stroke study (DUST) by calculating area under the receiver operating curves (AUROC). With group lasso regression analysis, we constructed a prediction model, incorporating patient characteristics next to National Institutes of Health Stroke Scale (NIHSS) items. Finally, we developed a decision tree algorithm based on dichotomized NIHSS items. RESULTS We identified seven LAVO-prediction scales. From DUST, 1316 patients (35.8% LAVO-rate) from 14 centers were available for validation. FAST-ED and RACE had the highest AUROC (both >0.81, p < 0.01 for comparison with other scales). Group lasso analysis revealed a LAVO-prediction model containing seven NIHSS items (AUROC 0.84). With the GACE (Gaze, facial Asymmetry, level of Consciousness, Extinction/inattention) decision tree, LAVO is predicted (AUROC 0.76) for 61% of patients with assessment of only two dichotomized NIHSS items, and for all patients with four items. CONCLUSION External validation of seven LAVO-prediction scales showed AUROCs between 0.75 and 0.83. Most scales, however, appear too complex for Emergency Medical Services use with prehospital validation generally lacking. GACE is the first LAVO-prediction scale using a simple decision tree as such increasing feasibility, while maintaining high accuracy. Prehospital prospective validation is planned.
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Affiliation(s)
- Gaia T Koster
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - T Truc My Nguyen
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, Netherlands
| | - Bjarty L Garcia
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Hannah R Rowling
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - J Bosch
- Department of Research and Development, RAV Hollands Midden, Leiden, Netherlands
| | - Wouter J Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, Netherlands; Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht, Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Heleen M den Hertog
- Department of Neurology, Medisch Spectrum Twente; Department of Neurology, Isala Clinics, Zwolle, Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
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9
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Jansen IGH, Mulder MJHL, Goldhoorn RJB, Boers AMM, van Es ACGM, Yo LSF, Hofmeijer J, Martens JM, van Walderveen MAA, van der Kallen BFW, Jenniskens SFM, Treurniet KM, Marquering HA, Sprengers MES, Schonewille WJ, Bot JCJ, Lycklama a Nijeholt GJ, Lingsma HF, Liebeskind DS, Boiten J, Vos JA, Roos YBWEM, van Oostenbrugge RJ, van der Lugt A, van Zwam WH, Dippel DWJ, van den Wijngaard IR, Majoie CBLM. Impact of single phase CT angiography collateral status on functional outcome over time: results from the MR CLEAN Registry. J Neurointerv Surg 2019; 11:866-873. [DOI: 10.1136/neurintsurg-2018-014619] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 11/04/2022]
Abstract
BackgroundCollateral status modified the effect of endovascular treatment (EVT) for stroke in several randomized trials. We assessed the association between collaterals and functional outcome in EVT treated patients and investigated if this association is time dependent.MethodsWe included consecutive patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN) Registry (March 2014–June 2016) with an anterior circulation large vessel occlusion undergoing EVT. Functional outcome was measured on the modified Rankin Scale (mRS) at 90 days. We investigated the association between collaterals and mRS in the MR CLEAN Registry with ordinal logistic regression and if this association was time dependent with an interaction term. Additionally, we determined modification of EVT effect by collaterals compared with MR CLEAN controls, and also investigated if this was time dependent with multiplicative interaction terms.Results1412 patients were analyzed. Functional independence (mRS score of 0–2) was achieved in 13% of patients with grade 0 collaterals, in 27% with grade 1, in 46% with grade 2, and in 53% with grade 3. Collaterals were significantly associated with mRS (adjusted common OR 1.5 (95% CI 1.4 to 1.7)) and significantly modified EVT benefit (P=0.04). None of the effects were time dependent. Better collaterals corresponded to lower mortality (P<0.001), but not to lower rates of symptomatic intracranial hemorrhage (P=0.14).ConclusionIn routine clinical practice, better collateral status is associated with better functional outcome and greater treatment benefit in EVT treated acute ischemic stroke patients, independent of time to treatment. Within the 6 hour time window, a substantial proportion of patients with absent and poor collaterals can still achieve functional independence.
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10
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Ernst M, Boers AMM, Forkert ND, Berkhemer OA, Roos YB, Dippel DWJ, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Vettorazzi E, Fiehler J, Marquering HA, Majoie CBLM, Gellissen S. Impact of Ischemic Lesion Location on the mRS Score in Patients with Ischemic Stroke: A Voxel-Based Approach. AJNR Am J Neuroradiol 2018; 39:1989-1994. [PMID: 30287456 DOI: 10.3174/ajnr.a5821] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/07/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies indicated that ischemic lesion volume might be a useful surrogate marker for functional outcome in ischemic stroke but should be considered in the context of lesion location. In contrast to previous studies using the ROI approach, which has several drawbacks, the present study aimed to measure the impact of ischemic lesion location on functional outcome using a more precise voxelwise approach. MATERIALS AND METHODS Datasets of patients with acute ischemic strokes from the Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) were used. Primary outcome was functional outcome as assessed by the modified Rankin Scale 3 months after stroke. Ischemic lesion volume was determined on CT scans 3-9 days after stroke. Voxel-based lesion-symptom mapping techniques, including covariates that are known to be associated with functional outcome, were used to determine the impact of ischemic lesion location for outcome. RESULTS Of the 500 patients in the MR CLEAN trial, 216 were included for analysis. The mean age was 63 years. Lesion-symptom mapping with inclusion of covariates revealed that especially left-hemispheric lesions in the deep periventricular white matter and adjacent internal capsule showed a great influence on functional outcome. CONCLUSIONS Our study confirms that infarct location has an important impact on functional outcome of patients with stroke and should be considered in prediction models. After we adjusted for covariates, the left-hemispheric corticosubcortical fiber tracts seemed to be of higher functional importance compared with cortical lesions.
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Affiliation(s)
- M Ernst
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
| | - A M M Boers
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (A.M.M.B., H.A.M.).,Department of Robotics and Mechatronics (A.M.M.B.), University of Twente, Enschede, the Netherlands
| | - N D Forkert
- Department of Radiology and Hotchkiss Brain Institute (N.D.F.), University of Calgary, Calgary, Alberta, Canada
| | - O A Berkhemer
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Departments of Neurology (O.A.B., D.W.J.D.).,Department of Radiology (O.A.B.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Y B Roos
- Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands
| | | | - A van der Lugt
- Radiology (A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - R J van Oostenbrugge
- Department of Neurology (R.J.v.O.), Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht, the Netherlands
| | - W H van Zwam
- Department of Radiology and Cardiovascular Research Institute Maastricht (W.H.v.Z.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - E Vettorazzi
- Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
| | - H A Marquering
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics (A.M.M.B., H.A.M.)
| | - C B L M Majoie
- Departments of Radiology and Nuclear Medicine (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.)
| | - S Gellissen
- From the Departments of Diagnostic and Interventional Neuroradiology (M.E., J.F., S.G.)
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11
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Zonneveld TP, Richard E, Vergouwen MDI, Nederkoorn PJ, de Haan RJ, Roos YBWEM, Kruyt ND. Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev 2018; 7:CD007858. [PMID: 30024023 PMCID: PMC6513249 DOI: 10.1002/14651858.cd007858.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Stroke is an important cause of death and disability worldwide. Since high blood pressure is an important risk factor for stroke and stroke recurrence, drugs that lower blood pressure might play an important role in secondary stroke prevention. OBJECTIVES To investigate whether blood pressure-lowering drugs (BPLDs) started at least 48 hours after the index event are effective for the prevention of recurrent stroke, major vascular events, and dementia in people with stroke or transient ischaemic attack (TIA). Secondary objectives were to identify subgroups of people in which BPLDs are effective, and to investigate the optimum systolic blood pressure target after stroke or TIA for preventing recurrent stroke, major vascular events, and dementia. SEARCH METHODS In August 2017, we searched the Trials Registers of the Cochrane Stroke Group and the Cochrane Hypertension Group, the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE Ovid (1946 to August 2017), Embase Ovid (1974 to August 2017), ClinicalTrials.gov, the ISRCTN Registry, Stroke Trials Registry, Trials Central, and the World Health Organization (WHO) International Clinical Trials Registry Platform Portal. SELECTION CRITERIA Randomised controlled trials (RCTs) of BPLDs started at least 48 hours after stroke or TIA. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts, selected eligible trials, extracted the data, assessed risk of bias, and used GRADE to assess the quality of the evidence. If necessary, we contacted the principal investigators or corresponding authors for additional data. MAIN RESULTS We included 11 studies involving a total of 38,742 participants: eight studies compared BPLDs versus placebo or no treatment (35,110 participants), and three studies compared different systolic blood pressure targets (3632 participants). The risk of bias varied greatly between included studies. The pooled risk ratios (RRs) of BPLDs were 0.81 (95% confidence interval (CI) 0.70 to 0.93; 8 RCTs; 35,110 participants; moderate-quality evidence), 0.90 (95% CI 0.78 to 1.04; 4 RCTs; 28,630 participants; high-quality evidence) for major vascular event, and 0.88 (95% CI 0.73 to 1.06; 2 RCTs; 6671 participants; high-quality evidence) for dementia. We mainly observed a reduced risk of recurrent stroke in the subgroup of participants using an angiotensin-converting enzyme (ACE) inhibitor or a diuretic (I2 statistic for subgroup differences 72.1%; P = 0.006). The pooled RRs of intensive blood pressure-lowering were 0.80 (95% CI 0.63 to 1.00) for recurrent stroke and 0.58 (95% CI 0.23 to 1.46) for major vascular event. AUTHORS' CONCLUSIONS Our results support the use of BPLDs in people with stroke or TIA for reducing the risk of recurrent stroke. Current evidence is primarily derived from trials studying an ACE inhibitor or a diuretic. No definite conclusions can be drawn from current evidence regarding an optimal systolic blood pressure target after stroke or TIA.
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Affiliation(s)
- Thomas P Zonneveld
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Edo Richard
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
- Radboud University Nijmegen Medical CenterDepartment of Neurology, Donders Institute for Brain, Behaviour and CognitionNijmegenNetherlands
| | - Mervyn DI Vergouwen
- University Medical Center UtrechtBrain Center Rudolf Magnus, Department of Neurology and NeurosurgeryUtrechtNetherlands
| | - Paul J Nederkoorn
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Rob J de Haan
- Amsterdam UMC, University of AmsterdamClinical Research UnitAmsterdamNetherlands
| | - Yvo BWEM Roos
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Nyika D Kruyt
- Leiden University Medical CenterDepartment of NeurologyLeidenNetherlands
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12
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Mulder MJHL, Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Majoie CBLM, van der Lugt A, Dippel DWJ. Treatment in patients who are not eligible for intravenous alteplase: MR CLEAN subgroup analysis. Int J Stroke 2016; 11:637-45. [DOI: 10.1177/1747493016641969] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/24/2016] [Indexed: 11/15/2022]
Abstract
Background and purpose Patients with acute ischemic stroke due to intracranial large vessel occlusion benefit from intra-arterial therapy. Uncertainty exists about the effect of intra-arterial therapy in patients with contraindications for treatment with intravenous alteplase treatment. Our aim was to describe the clinical characteristics of this subgroup of patients and whether intra-arterial therapy is as safe and effective as it is after intravenous alteplase treatment. Methods All 500 MR CLEAN patients were included and we distinguished between patients who were and were not treated with intravenous alteplase treatment. We estimated the effect of intra-arterial therapy on the shift on the modified Rankin Scale score with ordinal logistic regression analysis and tested for interaction of intravenous alteplase treatment with intra-arterial therapy on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results Fifty-five patients (11%) were not treated with intravenous alteplase treatment, mostly because of prolonged coagulation time tests or recent surgery. These patients were older and more often had atrial fibrillation or other vascular comorbidity. There was no interaction between intravenous alteplase treatment and intervention effect ( p = 0.927). Intra-arterial therapy effect size in patients without intravenous alteplase treatment was 2.06 [95% CI: 0.69–6.13] and in patients with intravenous alteplase treatment 1.71 [95% CI: 1.22–2.40]. There were no safety issues. Conclusions For patients with acute ischemic anterior circulation stroke caused by intracranial large vessel occlusion, who have contraindications for intravenous alteplase, intra-arterial treatment is not less effective or less safe than in patients who receive the treatment after intravenous alteplase. Clinical trial registration Clinical trial registration-URL: http://www.trialregister.nl . Unique identifier: (NTR)1804. Clinical trial registration-URL: http://www.controlled-trials.com . Unique identifier: ISRCTN10888758.
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Affiliation(s)
| | | | - Puck SS Fransen
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Debbie Beumer
- Maastricht University Medical Center, Maastricht, Cardiovascular Research Institute Maastricht (CARIM), the Netherlands
| | | | | | | | - Robert J van Oostenbrugge
- Maastricht University Medical Center, Maastricht, Cardiovascular Research Institute Maastricht (CARIM), the Netherlands
| | - Wim H van Zwam
- Maastricht University Medical Center, Maastricht, Cardiovascular Research Institute Maastricht (CARIM), the Netherlands
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13
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Wiegerinck EMA, van Kesteren F, Planken RN, Roos YBWEM, Majoie CBLM, van der Wal AC, Baan J. Thromboembolic events after transcatheter aortic valve implantation. Int J Stroke 2015; 11:NP13-5. [DOI: 10.1177/1747493015609934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Esther MA Wiegerinck
- Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Floortje van Kesteren
- Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Robrecht N Planken
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Academic Medical Center, Univeristy of Amsterdam, Amsterdam, the Netherlands
| | - Charles BLM Majoie
- Department of Neuro-Radiology, Academic Medical Center, Univeristy of Amsterdam, Amsterdam, the Netherlands
| | - Allard C van der Wal
- Department of Pathology, Academic Medical Center, University of Amsterdam. Amsterdam, the Netherlands
| | - Jan Baan
- Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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14
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Fransen PSS, Beumer D, Berkhemer OA, van den Berg LA, Lingsma H, van der Lugt A, van Zwam WH, van Oostenbrugge RJ, Roos YBWEM, Majoie CB, Dippel DWJ. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials 2014; 15:343. [PMID: 25179366 PMCID: PMC4162915 DOI: 10.1186/1745-6215-15-343] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Endovascular or intra-arterial treatment (IAT) increases the likelihood of recanalization in patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion. However, a beneficial effect of IAT on functional recovery in patients with acute ischemic stroke remains unproven. The aim of this study is to assess the effect of IAT on functional outcome in patients with acute ischemic stroke. Additionally, we aim to assess the safety of IAT, and the effect on recanalization of different mechanical treatment modalities. METHODS/DESIGN A multicenter randomized clinical trial with blinded outcome assessment. The active comparison is IAT versus no IAT. IAT may consist of intra-arterial thrombolysis with alteplase or urokinase, mechanical treatment or both. Mechanical treatment refers to retraction, aspiration, sonolysis, or use of a retrievable stent (stent-retriever). Patients with a relevant intracranial proximal arterial occlusion of the anterior circulation, who can be treated within 6 hours after stroke onset, are eligible. Treatment effect will be estimated with ordinal logistic regression (shift analysis); 500 patients will be included in the trial for a power of 80% to detect a shift leading to a decrease in dependency in 10% of treated patients. The primary outcome is the score on the modified Rankin scale at 90 days. Secondary outcomes are the National Institutes of Health stroke scale score at 24 hours, vessel patency at 24 hours, infarct size on day 5, and the occurrence of major bleeding during the first 5 days. DISCUSSION If IAT leads to a 10% absolute reduction in poor outcome after stroke, careful implementation of the intervention could save approximately 1% of all new stroke cases from death or disability annually. TRIAL REGISTRATION NTR1804 (7 May 2009)/ISRCTN10888758 (24 July 2012).
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Affiliation(s)
- Puck SS Fransen
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Debbie Beumer
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Olvert A Berkhemer
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Lucie A van den Berg
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Hester Lingsma
- />Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Aad van der Lugt
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Wim H van Zwam
- />Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Yvo BWEM Roos
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Charles B Majoie
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
| | - Diederik WJ Dippel
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
| | - for the MR CLEAN Investigators
- />Department of Neurology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Neurology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
- />Department of Radiology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Neurology, Academisch Medisch Centrum, PO Box 22660, 1100 DD Amsterdam, the Netherlands
- />Department of Public Health, Erasmus MC University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands
- />Department of Radiology, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, the Netherlands
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Abstract
BACKGROUND Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to dissolution of the blood clot at the site of aneurysm rupture by natural fibrinolytic activity. This review is an update of a previously published Cochrane review. OBJECTIVES To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1948 to December 2012), and EMBASE (1947 to December 2012). In an effort to identify further published, unpublished, and ongoing studies we searched reference lists and trial registers, performed forward tracking of relevant references and contacted drug companies. SELECTION CRITERIA Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted the data. Three review authors assessed trial quality. For the primary outcome we converted the outcome scales between good and poor outcome for the analysis. We scored death from any cause and rates of rebleeding, cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. MAIN RESULTS We included 10 trials involving 1904 participants. The risk of bias was low in six studies. Four studies were open label and were rated as high risk of performance bias. One of these studies was also rated as high risk for attrition bias. Four trials reported on poor outcome (death, vegetative state, or severe disability) with a pooled risk ratio (RR) of 1.02 (95% confidence interval (CI) 0.91 to 1.15). All trials reported on death from all causes with a pooled RR of 1.00 (95% CI 0.85 to 1.18). In a trial that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for cerebral ischaemia the RR for poor outcome was 0.85 (95% CI 0.64 to 1.14). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up (RR 0.65, 95% CI 0.44 to 0.97; 78 per 1000 participants), but there was heterogeneity (I² = 62%) between the trials. The pooled RR for reported cerebral ischaemia was 1.41 (95% CI 1.04 to 1.91, 83 per 1000 participants), again with heterogeneity between the trials (I² = 52%). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (RR 1.11, 95% CI 0.90 to 1.36). AUTHORS' CONCLUSIONS The current evidence does not support the use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage, even in those who have concomitant treatment strategies to prevent cerebral ischaemia. Results on short-term treatment are promising, but not conclusive. Further randomised trials evaluating short-term antifibrinolytic treatment are needed to evaluate its effectiveness.
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Affiliation(s)
- Merih I Baharoglu
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Menno R Germans
- University of AmsterdamDepartment of Neurosurgery, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Center for Health Sciences and Primary Care/University Department of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Marinus Vermeulen
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Jan van Gijn
- University Medical Center UtrechtDepartment of NeurologyPO Box 85500UtrechtNetherlands3508 GA
| | - Yvo BWEM Roos
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
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Ubbink DT, Vermeulen H, Knops AM, Legemate DA, Oude Rengerink K, Heineman MJ, Roos YB, Fijnvandraat CJ, Heymans HS, Simons R, Levi M. Implementation of evidence-based practice: outside the box, throughout the hospital. Neth J Med 2011; 69:87-94. [PMID: 21411849] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Evidence-based practice (EBP) is a generally accepted means to improve healthcare quality. However, not all healthcare professionals and managers apply EBP in daily practice. We investigated EBP attitudes, knowledge and the perceived barriers and facilitators to practising EBP , to define tailor-made interventions for improving evidence-based behaviour. METHODS In this cross-sectional survey, doctors and nurses from five major specialities of a university hospital were invited to complete the McColl and Barriers questionnaires. RESULTS Response rates were 70% (305÷435) for doctors and 74% (396÷537) for nurses. They were welcoming towards EBP, but considered time constraints, knowledge gaps and poor availability of evidence as major barriers to implement EBP . They also mentioned contradicting results (75%) and flawed methodology (69%), while nurses frequently mentioned unawareness of (75%), or difficulty in reading and interpreting research papers (70%). Regarding EBP knowledge, 6/8 common EBP terms could be explained by 54% of doctors but by only 15% of nurses. Facilitating factors among doctors concerned the availability and accessibility of high-level evidence and communication of evidence during various clinical meetings and handovers for clinical decision making. Among nurses, promoting factors involved more teaching and instances to incorporate EBP in clinical practice. Both groups desired more managerial support in terms of motivation and opportunities. CONCLUSIONS Doctors and nurses have embraced the EBP paradigm as an important means to improve quality of clinical patient care, but its application is still cumbersome. This paper offers a tailored programme for implementation and managerial role-models.sustainment of EBP, corroborated by professional and managerial role-models.
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Affiliation(s)
- D T Ubbink
- Department of Quality Assurance & Process Innovation, University of Amsterdam, the Netherlands.
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Kruyt ND, Musters A, Biessels GJ, Devries JH, Coert BA, Vergouwen MDI, Horn J, Roos YB. Beta-cell dysfunction and insulin resistance after subarachnoid haemorrhage. Neuroendocrinology 2011; 93:126-32. [PMID: 21293115 DOI: 10.1159/000324097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 01/02/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hyperglycaemia is a common finding and an independent risk factor for increased morbidity and mortality in aneurysmal subarachnoid haemorrhage (SAH). Although in these patients hyperglycaemia is commonly ascribed to insulin resistance, there is little understanding of underlying mechanisms. AIMS To prospectively study temporal disturbances of glucose metabolism after aneurysmal SAH in patients without known abnormalities of glucose metabolism and to explore possible correlations with markers of stress. METHODS In consecutive aneurysmal SAH patients not subjected to insulin therapy, in-hospital and follow-up oral glucose tolerance tests (OGTTs) and assessments of insulin resistance, pancreatic β-cell function, free fatty acids (FFA) and cortisol were performed and compared with reference values. RESULTS We included 13 patients. In the first 2 weeks of admission, median fasting glucose and FFA levels were elevated while insulin levels were not. OGTTs were indicative of glucose intolerance in all patients at days 3 and 7, while on follow-up 1 patient had glucose intolerance and all patients had normal fasting glucose levels. Pancreatic β-cell function was impaired throughout the first week and insulin resistance from day 4 to 10. Levels of cortisol correlated with higher fasting glucose and increased FFA. FFA in turn correlated with pancreatic β-cell dysfunction. CONCLUSIONS Aneurysmal SAH patients have transient abnormalities of glucose metabolism. During the first week, it appears to result predominantly from transient pancreatic β-cell dysfunction, in combination with insulin resistance.
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Affiliation(s)
- N D Kruyt
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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18
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Zinkstok SM, Vermeulen M, Stam J, de Haan RJ, Roos YB. A randomised controlled trial of antiplatelet therapy in combination with Rt-PA thrombolysis in ischemic stroke: rationale and design of the ARTIS-Trial. Trials 2010; 11:51. [PMID: 20459856 PMCID: PMC2886039 DOI: 10.1186/1745-6215-11-51] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 05/12/2010] [Indexed: 12/20/2022] Open
Abstract
Background Thrombolysis with intravenous rt-PA is currently the only approved acute therapy for ischemic stroke. Re-occlusion after initial recanalization occurs in up to 34% in patients treated with rt-PA, probably caused by platelet activation. In acute myocardial infarction, the combination of thrombolysis and antiplatelet therapy leads to a greater reduction of mortality compared to thrombolysis alone. In patients with acute ischemic stroke, several studies showed that patients already on antiplatelet treatment prior to thrombolysis had an equal or even better outcome compared to patients without prior antiplatelet treatment, despite an increased risk of intracerebral bleeding. Based on the fear of intracerebral haemorrhage, current international guidelines recommend postponing antiplatelet therapy until 24 hours after thrombolysis. Remarkably, prior use of antiplatelet therapy is not a contra-indication for thrombolysis. We hypothesize that antiplatelet therapy in combination with rt-PA thrombolysis will improve outcome by enhancing fibrinolysis and preventing re-occlusion. Methods/Design ARTIS is a randomised multi-center controlled trial with blind endpoint assessment. Our objective is to investigate whether immediate addition of aspirin to rt-PA thrombolysis improves functional outcome in ischemic stroke. Patients with acute ischemic stroke eligible for rt-PA thrombolysis are randomised to receive 300 mg aspirin within 1.5 hours after start of thrombolysis or standard care, consisting of antiplatelet therapy after 24 hours. Primary outcome is poor functional health at 3 months follow-up (modified Rankin Scale 3 - 6). Discussion This is the first clinical trial investigating the combination of rt-PA and acute aspirin by means of a simple and cheap adjustment of current antiplatelet regimen. We expect the net benefit of improved functional outcome will overcome the possible slightly increased risk of intracerebral haemorrhage. Trial registration The Netherlands National Trial Register NTR822. The condensed rationale of the ARTIS-Trial has already been published in Cerebrovascular Diseases.
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Affiliation(s)
- S M Zinkstok
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands.
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19
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Vriesendorp TM, Roos YB, Kruyt ND, Biessels GJ, Kappelle LJ, Vermeulen M, Holleman F, DeVries JH, Hoekstra JBL. Efficacy and safety of two 5 day insulin dosing regimens to achieve strict glycaemic control in patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2009; 80:1040-3. [PMID: 19684236 DOI: 10.1136/jnnp.2008.144873] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In patients with acute ischaemic stroke and hyperglycaemia, prolonged strict glycaemic control may improve clinical outcome. The question is how to achieve this prolonged strict glycaemic control. In this study, the efficacy and safety of two regimens with different basal to meal related insulin ratio are described. METHODS 33 patients with ischaemic stroke and hyperglycaemia at admission were randomised in an open design to receive: (1) conventional glucose lowering therapy, (2) strict glucose control with predominantly basal insulin using intravenous insulin or (3) strict glucose control with predominantly meal related insulin using subcutaneous insulin in the first 5 days after stroke. The target range of glucose control for the last two groups was 4.4-6.1 mmol/l. 16 consecutive patients without hyperglycaemia at admission were included to serve as normoglycaemic controls. RESULTS The median area under the curve (AUC) in the meal related insulin group was 386 mmol/l x 58 h (range 286-662) for days 2-5, and did not differ from the hyperglycaemic control group (median AUC 444 mmol/l x 58 h; range 388-620). There was also no difference in median AUC of the basal insulin group (453 mmol/l x 58 h, range 347-629) and the hyperglycaemic control group on days 2-5. In the first 12 hours, glucose profiles were lower in the groups treated with strict glucose control; median AUC was 90 mmol/l x 12 h (range 77-189) for the hyperglycaemic control group versus 81 mmol/l x 12 h (range 60-118) for the meal related insulin group (p = 0.03) and 74 mmol/l x 12 h (range 52-97) for the basal insulin group (p = 0.008). CONCLUSION In intermittently fed ischaemic stroke patients, strict glycaemic control between day 2 and day 5 with two different basal bolus regimens did not result in lower glucose profiles due to postprandial hyperglycaemia. Continuous enteral feeding may therefore be needed to achieve prolonged strict glycaemic control in acute stroke patients.
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Affiliation(s)
- T M Vriesendorp
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Vergouwen MDI, de Haan R, van Gool WA, Vermeulen M, Roos YBWEM. Blood-pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attacks. Hippokratia 2009. [DOI: 10.1002/14651858.cd007858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mervyn DI Vergouwen
- University of Amsterdam; Department of Neurology, Academic Medical Centre; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Rob de Haan
- Academic Medical Centre, University of Amsterdam; Clinical Epidemiology and Biostatistics; PO Box 22700 Amsterdam Netherlands 1100 DE
| | - Willem A van Gool
- University of Amsterdam; Department of Neurology, Academic Medical Centre; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Marinus Vermeulen
- University of Amsterdam; Department of Neurology, Academic Medical Centre; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
| | - Yvo BWEM Roos
- University of Amsterdam; Department of Neurology, Academic Medical Centre; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Weisscher N, Vermeulen M, Roos YB, de Haan RJ. What should be defined as good outcome in stroke trials; a modified Rankin score of 0-1 or 0-2? J Neurol 2008; 255:867-74. [PMID: 18338195 DOI: 10.1007/s00415-008-0796-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 10/22/2007] [Accepted: 10/29/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Good outcome in stroke trials has been defined as a modified Rankin scale (mRs) score of 0-1 or 0-2. The aim of this study was to investigate the clinical meaning of these two dichotomies. METHODS We studied 152 patients six months post stroke using the mRs and a new disability measure the AMC Linear Disability Scale (ALDS) item bank. Descriptive statistics were used to show the ALDS scores by the levels of the mRs. To investigate the clinical meaning of the different definitions of good outcome, the mean probability to perform activities of daily life (ADL) of all mRs grades and these two dichotomies was calculated. RESULTS The ability to perform difficult ALDS items declined gradually with increasing mRs grade. When favourable outcome is defined as mRs 0-1, 15 % of the cohort has a good outcome; of these patients 84 % were likely to perform outdoor activities. If good outcome is defined as mRs 0-2, the percentage of patients with good outcome increased to 37 %, whereas 66 % of these patients were likely to perform outdoor activities. CONCLUSION If good outcome is defined as the ability to perform outdoor activities mRs 0-1 should be chosen. If complex ADL are considered as good outcome mRs 0-2 is the outcome measure of choice. Independent of which outcome measure is chosen, the treatment effect in clinical trials must be large before good outcome is achieved. Therefore, it is likely that clinically important treatment effects can be missed in clinical trials with both these mRs endpoints.
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Affiliation(s)
- N Weisscher
- Dept. of Neurology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Abstract
BACKGROUND AND PURPOSE The purpose of this study was first, to investigate which factor in the fibrinolytic cascade is responsible for the recently observed increase of fibrinolytic activity in patients with aneurysmal subarachnoid hemorrhage (SAH), and second, the cause of this increase. METHODS Fibrinolytic activity and the main regulators of endogenous fibrinolytic activity, tissue plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) were measured in patients treated with and without nimodipine. RESULTS In patients with aneurysmal SAH, fibrinolytic activity significantly increases from 2.7 IU/mL on admission to 4.2 IU/mL in week 3 (P<0.01, paired-sample t test), caused by a 1.6-fold decrease in plasma levels of PAI-1. The results also show that increased fibrinolytic activity is seen only in patients treated with nimodipine and that plasminogen activity and PAI-1 returned to baseline levels after treatment with nimodipine had been discontinued. CONCLUSIONS The mechanism of increased fibrinolytic activity in patients with aneurysmal SAH is a decrease in the level of PAI-1, which is most likely caused by treatment with nimodipine.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
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Roos YB, de Haan RJ, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M. Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands. J Neurol Neurosurg Psychiatry 2000; 68:337-41. [PMID: 10675216 PMCID: PMC1736841 DOI: 10.1136/jnnp.68.3.337] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated effect on outcome will be of improved treatment. METHODS A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed. RESULTS Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the effects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively. CONCLUSIONS In two thirds of the patients with poor outcome the causes of poor outcome are the effects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor effects on the outcome of patients with subarachnoid haemorrhage.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Roos YB, Vermeulen M, Rinkel GJ, Algra A, Van Gijn J, Algra A. Systematic review of antifibrinolytic treatment in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1998; 65:942-3. [PMID: 9854979 PMCID: PMC2170374 DOI: 10.1136/jnnp.65.6.942] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, The Netherlands.
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Roos YB, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M. Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. J Neurol Neurosurg Psychiatry 1997; 63:490-3. [PMID: 9343129 PMCID: PMC2169792 DOI: 10.1136/jnnp.63.4.490] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. METHODS A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. RESULTS The proportion of patients that was operated on early--that is, within three days after SAH--was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. CONCLUSIONS In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Centre, University of Amsterdam, The Netherlands
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Abstract
Patients with large amounts of intraventricular blood have a poor prognosis. The question is whether the quantity of ventricular blood or other factors related to the origin of the intraventricular bleeding cause poor outcome. The association between ventricular blood volume and outcome was analysed in patients with a primary intraventricular haemorrhage (PIVH) and in patients with an aneurysmal subarachnoid haemorrhage (SAH). The medical records of 24 patients with PIVH were reviewed and these patients were compared with 59 patients selected from a prospectively studied series of patients with aneurysmal SAH who had intraventricular blood without an intraparenchymal haematoma. Glasgow coma score on admission and outcome at three months expressed on the Glasgow outcome scale were available for all patients. Volumetric analysis on CT was carried out if there was at least a moderate amount of blood measured with a semi-quantitative scale (SAH n = 30, PIVH n = 22). In patients with SAH more than 20 ml intraventricular blood was lethal, as previously shown for patients with intraparenchymal haemorrhage. Patients with a PIVH can, however, survive such large volumes of intraventricular blood without impaired consciousness immediately after the bleeding, without developing hydrocephalus, and without any disability after three months. It is concluded that the cause of an intraventricular haemorrhage is more important for outcome than the amount of intraventricular blood, and large intraventricular haemorrhages are not always associated with hydrocephalus.
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Affiliation(s)
- Y B Roos
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
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