Pub Date : 2024-09-01Epub Date: 2024-02-15DOI: 10.1177/23969873241231702
Rahul G Muthalaly, Timothy B Abrahams, Nitesh Nerlekar, Adam J Nelson, Sean Tan, Jasmine Chan, Thanh Phan, Henry Ma, Stephen J Nicholls
Background: Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors.
Patients and methods: We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses.
Results: We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (I2 = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (I2 = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity I2 = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, p = 0.007) for future MACE.
Discussion and conclusions: Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.
{"title":"Asymptomatic coronary artery disease in ischaemic stroke survivors: A systematic review and meta-analysis.","authors":"Rahul G Muthalaly, Timothy B Abrahams, Nitesh Nerlekar, Adam J Nelson, Sean Tan, Jasmine Chan, Thanh Phan, Henry Ma, Stephen J Nicholls","doi":"10.1177/23969873241231702","DOIUrl":"10.1177/23969873241231702","url":null,"abstract":"<p><strong>Background: </strong>Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors.</p><p><strong>Patients and methods: </strong>We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses.</p><p><strong>Results: </strong>We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (<i>I</i><sup>2</sup> = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (<i>I</i><sup>2</sup> = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity <i>I</i><sup>2</sup> = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, <i>p</i> = 0.007) for future MACE.</p><p><strong>Discussion and conclusions: </strong>Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"540-554"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418521/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139736347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-25DOI: 10.1177/23969873241234713
Adam T Mierzwa, Ashley Nelson, Sami Al Kasab, Santiago Ortega Gutierrez, Juan Vivanco-Suarez, Mudassir Farooqui, Ashutosh P Jadhav, Shashvat Desai, Gabor Toth, Anas Alrohimi, Thanh N Nguyen, Piers Klein, Mohamad Abdalkader, Hisham Salahuddin, Aditya Pandey, Zachary Wilseck, Sravanthi Koduri, Niraj Vora, Nameer Aladamat, Khaled Gharaibeh, Ehad Afreen, Hisham Al-Hajala, Julie Shawver, Syed Zaidi, Mouhammad Jumaa
Introduction: Recent randomized controlled trials demonstrated superiority of mechanical thrombectomy compared to medical therapy in acute basilar artery occlusions, however, little data is available to guide clinicians in functional prognosis and risk stratification.
Patients and methods: Data from the retrospectively established PC-SEARCH Thrombectomy registry, which included patients with basilar artery occlusion from eight sites from January 2015 to December 2021, was interrogated. Outcomes were dichotomized into 90-day favorable (mRS ⩽ 3) and unfavorable (mRS > 3). Multivariate logistic regression analysis was performed with respect to the outcome groups and were adjusted for potential confounding baseline characteristics.
Results: Four-hundred-forty-four patients were included in this analysis. Mean age was 66 [SD 15], with 56% male, and comprised of 76% Caucasian. Patients presented with an initial median NIHSS of 18 and 199 patients (44.8%) achieved favorable 90-day functional outcomes. Independent predictors of favorable outcomes included younger age, pc-ASPECTS > 8 (OR 2.30 p < 0.001), and TICI ⩾ 2b (OR 7.56 p < 0.001). Unfavorable outcomes were associated with increasing number of passes (OR 1.29 p = 0.004) and sICH (OR 4.19 p = 0.015). IA-tPA was an independent risk factor for sICH (OR 7.15 p = 0.002) without improving favorable functional outcomes.
Conclusion and discussion: PC-ASPECTS > 8, successful recanalization (TICI ⩾ 2b), first-pass recanalization, and younger age are independent predictors of favorable 90-day functional outcome in thrombectomy treated patients with acute basilar artery occlusion. Conversely, sICH were independent predictors of unfavorable outcomes. IA-tPA and unsuccessful recanalization are independently associated with sICH.
{"title":"Predictors of outcome and symptomatic intracranial hemorrhage in acute basilar artery occlusions: Analysis of the PC-SEARCH thrombectomy registry.","authors":"Adam T Mierzwa, Ashley Nelson, Sami Al Kasab, Santiago Ortega Gutierrez, Juan Vivanco-Suarez, Mudassir Farooqui, Ashutosh P Jadhav, Shashvat Desai, Gabor Toth, Anas Alrohimi, Thanh N Nguyen, Piers Klein, Mohamad Abdalkader, Hisham Salahuddin, Aditya Pandey, Zachary Wilseck, Sravanthi Koduri, Niraj Vora, Nameer Aladamat, Khaled Gharaibeh, Ehad Afreen, Hisham Al-Hajala, Julie Shawver, Syed Zaidi, Mouhammad Jumaa","doi":"10.1177/23969873241234713","DOIUrl":"10.1177/23969873241234713","url":null,"abstract":"<p><strong>Introduction: </strong>Recent randomized controlled trials demonstrated superiority of mechanical thrombectomy compared to medical therapy in acute basilar artery occlusions, however, little data is available to guide clinicians in functional prognosis and risk stratification.</p><p><strong>Patients and methods: </strong>Data from the retrospectively established PC-SEARCH Thrombectomy registry, which included patients with basilar artery occlusion from eight sites from January 2015 to December 2021, was interrogated. Outcomes were dichotomized into 90-day favorable (mRS ⩽ 3) and unfavorable (mRS > 3). Multivariate logistic regression analysis was performed with respect to the outcome groups and were adjusted for potential confounding baseline characteristics.</p><p><strong>Results: </strong>Four-hundred-forty-four patients were included in this analysis. Mean age was 66 [SD 15], with 56% male, and comprised of 76% Caucasian. Patients presented with an initial median NIHSS of 18 and 199 patients (44.8%) achieved favorable 90-day functional outcomes. Independent predictors of favorable outcomes included younger age, pc-ASPECTS > 8 (OR 2.30 <i>p</i> < 0.001), and TICI ⩾ 2b (OR 7.56 <i>p</i> < 0.001). Unfavorable outcomes were associated with increasing number of passes (OR 1.29 <i>p</i> = 0.004) and sICH (OR 4.19 <i>p</i> = 0.015). IA-tPA was an independent risk factor for sICH (OR 7.15 <i>p</i> = 0.002) without improving favorable functional outcomes.</p><p><strong>Conclusion and discussion: </strong>PC-ASPECTS > 8, successful recanalization (TICI ⩾ 2b), first-pass recanalization, and younger age are independent predictors of favorable 90-day functional outcome in thrombectomy treated patients with acute basilar artery occlusion. Conversely, sICH were independent predictors of unfavorable outcomes. IA-tPA and unsuccessful recanalization are independently associated with sICH.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"583-591"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418451/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139973881","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-03-18DOI: 10.1177/23969873241239208
Tolga D Dittrich, Tennessee von Streng, Anna M Toebak, Annaelle Zietz, Benjamin Wagner, Martin Hänsel, Raoul Sutter, Mira Katan, Nils Peters, Lars Michels, Zsolt Kulcsár, Grzegorz M Karwacki, Marco Pileggi, Carlo W Cereda, Susanne Wegener, Leo H Bonati, Marios Psychogios, Gian Marco De Marchis
Introduction: The impact of leptomeningeal collateralization on the efficacy of mechanical thrombectomy (MT) in patients with anterior circulation large vessel occlusion (aLVO) presenting in the 6-24 h time window remains poorly elucidated.
Patients and methods: Retrospective multicenter study of aLVO patients presenting between 6 and 24 h after stroke onset who received MT plus Best Medical Treatment (BMT) or BMT alone. Leptomeningeal collateralization was assessed using single-phase computed tomography angiography (grade 0: no filling; grade 1: filling ⩽50%; grade 2: filling >50% but <100%; grade 3: filling 100% of the occluded territory). Inverse probability of treatment weighted ordinal regression was performed to assess the association between treatment and shift of the modified Rankin Scale (mRS) score toward lower categories at 3 months. We used interaction analysis to explore differential treatment effects on functional outcomes (probabilities for each mRS subcategory at 3 months) at different collateral grades.
Results: Among 363 included patients, 62% received MT + BMT. Better collateralization was associated with better functional outcomes at 3 months in the BMT alone group (collateral grade 1 vs 0: acOR 5.06, 95% CI 2.33-10.99). MT + BMT was associated with higher odds of favorable functional outcome at 3 months (acOR 1.70, 95% CI 1.11-2.62) which was consistent after adjustment for collateral status (acOR 1.54, 95% CI 1.01-2.35). Regarding treatment effect modification, patients with absent collateralization had higher probabilities for a mRS of 0-4 and a lower mortality at 3 months for the MT + BMT group.
Discussion and conclusion: In the 6-to-24-h time window, aLVO patients with absent leptomeningeal collateralization benefit most from MT + BMT, indicating potential advantages for this group despite their poorer baseline prognosis.
导言:对于在 6-24 小时时间窗内出现的前循环大血管闭塞(aLVO)患者,脑膜侧支对机械取栓术(MT)疗效的影响仍未得到充分阐明:回顾性多中心研究:研究对象为卒中发生后6至24小时内接受MT加最佳医疗(BMT)或单纯BMT治疗的前循环大血管闭塞(aLVO)患者。使用单相计算机断层扫描血管造影评估脑膜侧支(0级:无充盈;1级:充盈⩽50%;2级:充盈>50%):在363名患者中,62%接受了MT+BMT治疗。在单纯 BMT 组中,更好的侧支与 3 个月后更好的功能预后相关(侧支等级 1 vs 0:acOR 5.06,95% CI 2.33-10.99)。MT + BMT 与 3 个月后的良好功能预后的更高几率相关(acOR 1.70,95% CI 1.11-2.62),这与调整侧支状态后的结果一致(acOR 1.54,95% CI 1.01-2.35)。在治疗效果调整方面,MT + BMT 组患者的 mRS 为 0-4 的概率更高,3 个月时的死亡率更低:讨论与结论:在6至24小时的时间窗内,无脑侧膜的aLVO患者从MT+BMT中获益最多,这表明尽管这组患者的基线预后较差,但仍有潜在的优势。
{"title":"Absent leptomeningeal collateralization is associated with greatest benefit from mechanical thrombectomy in the 6-24 hour time window.","authors":"Tolga D Dittrich, Tennessee von Streng, Anna M Toebak, Annaelle Zietz, Benjamin Wagner, Martin Hänsel, Raoul Sutter, Mira Katan, Nils Peters, Lars Michels, Zsolt Kulcsár, Grzegorz M Karwacki, Marco Pileggi, Carlo W Cereda, Susanne Wegener, Leo H Bonati, Marios Psychogios, Gian Marco De Marchis","doi":"10.1177/23969873241239208","DOIUrl":"10.1177/23969873241239208","url":null,"abstract":"<p><strong>Introduction: </strong>The impact of leptomeningeal collateralization on the efficacy of mechanical thrombectomy (MT) in patients with anterior circulation large vessel occlusion (aLVO) presenting in the 6-24 h time window remains poorly elucidated.</p><p><strong>Patients and methods: </strong>Retrospective multicenter study of aLVO patients presenting between 6 and 24 h after stroke onset who received MT plus Best Medical Treatment (BMT) or BMT alone. Leptomeningeal collateralization was assessed using single-phase computed tomography angiography (grade 0: no filling; grade 1: filling ⩽50%; grade 2: filling >50% but <100%; grade 3: filling 100% of the occluded territory). Inverse probability of treatment weighted ordinal regression was performed to assess the association between treatment and shift of the modified Rankin Scale (mRS) score toward lower categories at 3 months. We used interaction analysis to explore differential treatment effects on functional outcomes (probabilities for each mRS subcategory at 3 months) at different collateral grades.</p><p><strong>Results: </strong>Among 363 included patients, 62% received MT + BMT. Better collateralization was associated with better functional outcomes at 3 months in the BMT alone group (collateral grade 1 vs 0: acOR 5.06, 95% CI 2.33-10.99). MT + BMT was associated with higher odds of favorable functional outcome at 3 months (acOR 1.70, 95% CI 1.11-2.62) which was consistent after adjustment for collateral status (acOR 1.54, 95% CI 1.01-2.35). Regarding treatment effect modification, patients with absent collateralization had higher probabilities for a mRS of 0-4 and a lower mortality at 3 months for the MT + BMT group.</p><p><strong>Discussion and conclusion: </strong>In the 6-to-24-h time window, aLVO patients with absent leptomeningeal collateralization benefit most from MT + BMT, indicating potential advantages for this group despite their poorer baseline prognosis.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"592-599"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418553/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140144315","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-03-19DOI: 10.1177/23969873241240829
Marine Giroud, Mélanie Planton, Jean Darcourt, Nicolas Raposo, Pierre Brandicourt, Hélène Mirabel, Dominique Hervé, Alain Viguier, Jean-François Albucher, Jérémie Pariente, Jean Marc Olivot, Fabrice Bonneville, Patrice Péran, Lionel Calviere
Introduction: In Moyamoya angiopathy (MMA), mechanisms underlying cognitive impairment remain debated. We aimed to assess the association of cognitive impairment with the degree and the topography of cerebral hypoperfusion in MMA.
Methods: A retrospective analysis of neuropsychological and perfusion MRI data from adults with MMA was performed. Ischemic and haemorrhagic lesion masks were created to account for cerebral lesions in the analysis of cerebral perfusion. Whole brain volume of hypoperfused parenchyma was outlined on perfusion maps using different Tmax thresholds from 4 to 12 s. Regional analysis produced mean Tmax values at different regions of interest. Analyses compared perfusion ratios in patients with and without cognitive impairment, with multivariable logistic regression analysis to identify predictive factors.
Results: Cognitive impairment was found in 20/48 (41.7%) patients. Attention/processing speed and memory were equally impaired (24%) followed by executive domain (23%). After adjustment, especially for lesion volume, hypoperfused parenchyma volume outlined by Tmax > 4 s or Tmax > 5 s thresholds was an independent factor of cognitive impairment (OR for Tmax > 4 s = 1.06 [CI 95% 1.008-1.123]) as well as attention/processing speed (OR for Tmax > 4 s = 1.07 [CI 95% 1.003-1.133]) and executive domains (OR for Tmax > 5 s = 1.08 [CI 95% 1.004-1.158]). Regarding cognitive functions, patients with processing speed and flexibility impairment had higher frontal Tmax compared to other ROIs and to patients with normal test scores.
Discussion: Cerebral hypoperfusion emerged as an independent factor of cognitive impairment in MMA particularly in attention/processing speed and executive domains, with a strong contribution of frontal areas.
Conclusion: Considering this association, revascularization surgery could improve cognitive impairment.
导言:在莫亚莫亚血管病(MMA)中,认知障碍的潜在机制仍存在争议。我们的目的是评估认知障碍与 MMA 脑灌注不足的程度和形貌之间的关联:方法:我们对成人 MMA 患者的神经心理学和灌注 MRI 数据进行了回顾性分析。在分析脑灌注时,创建了缺血性和出血性病变掩膜,以考虑脑部病变。使用 4 至 12 秒的不同 Tmax 阈值在灌注图上勾勒出低灌注实质的整个脑容量。区域分析得出不同感兴趣区域的平均 Tmax 值。分析比较了有认知障碍和无认知障碍患者的灌注比率,并通过多变量逻辑回归分析确定了预测因素:20/48(41.7%)名患者存在认知障碍。注意力/处理速度和记忆力同样受损(24%),其次是执行领域(23%)。经过调整,特别是对病变体积进行调整后,Tmax > 4 s 或 Tmax > 5 s 临界值所概括的高灌注实质体积是认知障碍的独立因素(Tmax > 4 s 的 OR = 1.06 [CI 95% 1.008-1.123]),注意力/处理速度(Tmax > 4 s 的 OR = 1.07 [CI 95% 1.003-1.133])和执行领域(Tmax > 5 s 的 OR = 1.08 [CI 95% 1.004-1.158])也是独立因素。在认知功能方面,与其他ROI和测试评分正常的患者相比,处理速度和灵活性受损的患者额叶Tmax更高:讨论:脑灌注不足是MMA认知功能障碍的一个独立因素,尤其是在注意力/处理速度和执行力方面,额叶区域的贡献很大:结论:考虑到这一关联,血管再通手术可改善认知障碍。
{"title":"MRI hypoperfusion as a determinant of cognitive impairment in adults with Moyamoya angiopathy.","authors":"Marine Giroud, Mélanie Planton, Jean Darcourt, Nicolas Raposo, Pierre Brandicourt, Hélène Mirabel, Dominique Hervé, Alain Viguier, Jean-François Albucher, Jérémie Pariente, Jean Marc Olivot, Fabrice Bonneville, Patrice Péran, Lionel Calviere","doi":"10.1177/23969873241240829","DOIUrl":"10.1177/23969873241240829","url":null,"abstract":"<p><strong>Introduction: </strong>In Moyamoya angiopathy (MMA), mechanisms underlying cognitive impairment remain debated. We aimed to assess the association of cognitive impairment with the degree and the topography of cerebral hypoperfusion in MMA.</p><p><strong>Methods: </strong>A retrospective analysis of neuropsychological and perfusion MRI data from adults with MMA was performed. Ischemic and haemorrhagic lesion masks were created to account for cerebral lesions in the analysis of cerebral perfusion. Whole brain volume of hypoperfused parenchyma was outlined on perfusion maps using different Tmax thresholds from 4 to 12 s. Regional analysis produced mean Tmax values at different regions of interest. Analyses compared perfusion ratios in patients with and without cognitive impairment, with multivariable logistic regression analysis to identify predictive factors.</p><p><strong>Results: </strong>Cognitive impairment was found in 20/48 (41.7%) patients. Attention/processing speed and memory were equally impaired (24%) followed by executive domain (23%). After adjustment, especially for lesion volume, hypoperfused parenchyma volume outlined by Tmax > 4 s or Tmax > 5 s thresholds was an independent factor of cognitive impairment (OR for Tmax > 4 s = 1.06 [CI 95% 1.008-1.123]) as well as attention/processing speed (OR for Tmax > 4 s = 1.07 [CI 95% 1.003-1.133]) and executive domains (OR for Tmax > 5 s = 1.08 [CI 95% 1.004-1.158]). Regarding cognitive functions, patients with processing speed and flexibility impairment had higher frontal Tmax compared to other ROIs and to patients with normal test scores.</p><p><strong>Discussion: </strong>Cerebral hypoperfusion emerged as an independent factor of cognitive impairment in MMA particularly in attention/processing speed and executive domains, with a strong contribution of frontal areas.</p><p><strong>Conclusion: </strong>Considering this association, revascularization surgery could improve cognitive impairment.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"732-742"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418512/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140159265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-17DOI: 10.1177/23969873241232820
Peter McMeekin, Martin James, Christopher I Price, Gary A Ford, Philip White
Introduction: To support decisions about thrombectomy provision, we have previously estimated the annual UK population eligible for treatment as ∼10% of stroke admissions. Since then, eight further randomised trials that could alter the eligibility rate have reported in 2021-23. We updated our estimates of the eligible population from these trials and other recent studies.
Patients and methods: An updated decision tree describing the EVT eligible population for UK stroke admissions was produced. Decision criteria were derived from the highest level of evidence available. For nodes where no specific RCT data existed, evidence was obtained from the latest systematic review(s) or the highest quality observational data.
Results: We estimate that 15,420 (approximately 15%) of admitted UK stroke patients are now eligible for thrombectomy, or 14,930 if advanced brain imaging using MRI/CT perfusion or collateral assessment were used in all patients. This is a 54% increase in our previous estimate in 2021. Over 50% of LAO strokes are now potentially eligible for thrombectomy. The increase in eligibility is principally due to a much larger cohort of later presenting and/or larger ischaemic core patients.
Conclusion: Most previously independent LAO stroke patients presenting within 24 h, even in the presence of a large ischaemic core on initial non-contrast CT, should be considered for thrombectomy with use of advanced brain imaging in those presenting beyond 12 h to identify salvageable penumbral brain tissue. Treatment in most patients remains critically time-dependent and our estimates should be interpreted with this in mind.
{"title":"The impact of large core and late treatment trials: An update on the modelled annual thrombectomy eligibility of UK stroke patients.","authors":"Peter McMeekin, Martin James, Christopher I Price, Gary A Ford, Philip White","doi":"10.1177/23969873241232820","DOIUrl":"10.1177/23969873241232820","url":null,"abstract":"<p><strong>Introduction: </strong>To support decisions about thrombectomy provision, we have previously estimated the annual UK population eligible for treatment as ∼10% of stroke admissions. Since then, eight further randomised trials that could alter the eligibility rate have reported in 2021-23. We updated our estimates of the eligible population from these trials and other recent studies.</p><p><strong>Patients and methods: </strong>An updated decision tree describing the EVT eligible population for UK stroke admissions was produced. Decision criteria were derived from the highest level of evidence available. For nodes where no specific RCT data existed, evidence was obtained from the latest systematic review(s) or the highest quality observational data.</p><p><strong>Results: </strong>We estimate that 15,420 (approximately 15%) of admitted UK stroke patients are now eligible for thrombectomy, or 14,930 if advanced brain imaging using MRI/CT perfusion or collateral assessment were used in all patients. This is a 54% increase in our previous estimate in 2021. Over 50% of LAO strokes are now potentially eligible for thrombectomy. The increase in eligibility is principally due to a much larger cohort of later presenting and/or larger ischaemic core patients.</p><p><strong>Conclusion: </strong>Most previously independent LAO stroke patients presenting within 24 h, even in the presence of a large ischaemic core on initial non-contrast CT, should be considered for thrombectomy with use of advanced brain imaging in those presenting beyond 12 h to identify salvageable penumbral brain tissue. Treatment in most patients remains critically time-dependent and our estimates should be interpreted with this in mind.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"566-574"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418430/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139898295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-29DOI: 10.1177/23969873241231125
Anne van der Meij, Ghislaine Holswilder, Marie Louise E Bernsen, Hendrikus Ja van Os, Jeannette Hofmeijer, Fianne Hm Spaander, Jasper M Martens, Ido R van den Wijngaard, Hester F Lingsma, Praneeta R Konduri, Charles Blm Majoie, Wouter J Schonewille, Diederik Wj Dippel, Nyika D Kruyt, Paul J Nederkoorn, Marianne Aa van Walderveen, Marieke Jh Wermer
Introduction: To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO).
Patients and methods: We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders.
Results: 3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86).
Discussion and conclusion: On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.
{"title":"Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy.","authors":"Anne van der Meij, Ghislaine Holswilder, Marie Louise E Bernsen, Hendrikus Ja van Os, Jeannette Hofmeijer, Fianne Hm Spaander, Jasper M Martens, Ido R van den Wijngaard, Hester F Lingsma, Praneeta R Konduri, Charles Blm Majoie, Wouter J Schonewille, Diederik Wj Dippel, Nyika D Kruyt, Paul J Nederkoorn, Marianne Aa van Walderveen, Marieke Jh Wermer","doi":"10.1177/23969873241231125","DOIUrl":"10.1177/23969873241231125","url":null,"abstract":"<p><strong>Introduction: </strong>To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO).</p><p><strong>Patients and methods: </strong>We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders.</p><p><strong>Results: </strong>3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86).</p><p><strong>Discussion and conclusion: </strong>On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"600-612"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418468/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139991486","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-15DOI: 10.1177/23969873241234134
Ynte M Ruigrok, Jan H Veldink, Mark K Bakker
Introduction: There is no non-invasive treatment to prevent aneurysmal subarachnoid hemorrhage (ASAH) caused by intracranial aneurysm (IA) rupture. We aimed to identify drug classes that may affect liability to IA using a genetic approach.
Patients and methods: Using genome-wide association summary statistics we calculated genetic correlation between unruptured IA (N = 2140 cases), ASAH (N = 5140) or the combined group, and liability to drug usage from 23 drug classes (N up to 320,000) independent of the risk factor high blood pressure. Next, we evaluated the causality and therapeutic potential of correlated drug classes using three different Mendelian randomization frameworks.
Results: Correlations with IA were found for antidepressants, paracetamol, acetylsalicylic acid, opioids, beta-blockers, and peptic ulcer and gastro-esophageal reflux disease drugs. MR showed no evidence that genetically predicted usage of these drug classes caused IA. Genetically predicted high responders to antidepressant drugs were at higher risk of IA (odds ratio [OR] = 1.61, 95% confidence interval (CI) = 1.09-2.39, p = 0.018) and ASAH (OR = 1.68, 95% CI = 1.07-2.65, p = 0.024) if they used antidepressant drugs. This effect was absent in non-users. For beta-blockers, additional analyses showed that this effect was not independent of blood pressure after all. A complex and likely pleiotropic relationship was found between genetic liability to chronic multisite pain, pain medication usage (paracetamol, acetylsalicylic acid, and opioids), and IA.
Conclusions: We did not find drugs decreasing liability to IA and ASAH but found that antidepressant drugs may increase liability. We observed pleiotropic relationships between IA and other drug classes and indications. Our results improve understanding of pathogenic mechanisms underlying IA.
导言:目前还没有一种非侵入性治疗方法可以预防由颅内动脉瘤(IA)破裂引起的动脉瘤性蛛网膜下腔出血(ASAH)。我们的目的是利用遗传学方法确定可能影响颅内动脉瘤易感性的药物类别:利用全基因组关联汇总统计,我们计算了未破裂IA(2140例)、ASAH(5140例)或合并组与23类药物(多达32万种)的药物使用责任之间的遗传相关性,而与高血压这一风险因素无关。接下来,我们使用三种不同的孟德尔随机框架评估了相关药物类别的因果关系和治疗潜力:结果:发现抗抑郁药、扑热息痛、乙酰水杨酸、阿片类药物、β-受体阻滞剂、消化性溃疡和胃食管反流病药物与内分泌相关。磁共振结果显示,没有证据表明基因预测的这些药物类别的使用会导致内分泌失调。基因预测的抗抑郁药物高反应者如果使用抗抑郁药物,罹患IA(几率比[OR] = 1.61,95% 置信区间(CI)= 1.09-2.39,p = 0.018)和ASAH(OR = 1.68,95% CI = 1.07-2.65,p = 0.024)的风险较高。未使用抗抑郁药物者则无此效应。对于β-受体阻滞剂,额外的分析表明这种效应与血压无关。我们发现,慢性多部位疼痛的遗传易感性、止痛药(扑热息痛、乙酰水杨酸和阿片类药物)的使用与内分泌之间存在复杂且可能是多效应的关系:结论:我们没有发现药物会降低对 IA 和 ASAH 的易感性,但发现抗抑郁药物可能会增加易感性。我们观察到原发性血管炎与其他药物类别和适应症之间的多效应关系。我们的研究结果增进了人们对诱发原发性心绞痛的致病机制的了解。
{"title":"Drug classes affecting intracranial aneurysm risk: Genetic correlation and Mendelian randomization.","authors":"Ynte M Ruigrok, Jan H Veldink, Mark K Bakker","doi":"10.1177/23969873241234134","DOIUrl":"10.1177/23969873241234134","url":null,"abstract":"<p><strong>Introduction: </strong>There is no non-invasive treatment to prevent aneurysmal subarachnoid hemorrhage (ASAH) caused by intracranial aneurysm (IA) rupture. We aimed to identify drug classes that may affect liability to IA using a genetic approach.</p><p><strong>Patients and methods: </strong>Using genome-wide association summary statistics we calculated genetic correlation between unruptured IA (<i>N</i> = 2140 cases), ASAH (<i>N</i> = 5140) or the combined group, and liability to drug usage from 23 drug classes (<i>N</i> up to 320,000) independent of the risk factor high blood pressure. Next, we evaluated the causality and therapeutic potential of correlated drug classes using three different Mendelian randomization frameworks.</p><p><strong>Results: </strong>Correlations with IA were found for antidepressants, paracetamol, acetylsalicylic acid, opioids, beta-blockers, and peptic ulcer and gastro-esophageal reflux disease drugs. MR showed no evidence that genetically predicted usage of these drug classes caused IA. Genetically predicted high responders to antidepressant drugs were at higher risk of IA (odds ratio [OR] = 1.61, 95% confidence interval (CI) = 1.09-2.39, <i>p</i> = 0.018) and ASAH (OR = 1.68, 95% CI = 1.07-2.65, <i>p</i> = 0.024) if they used antidepressant drugs. This effect was absent in non-users. For beta-blockers, additional analyses showed that this effect was not independent of blood pressure after all. A complex and likely pleiotropic relationship was found between genetic liability to chronic multisite pain, pain medication usage (paracetamol, acetylsalicylic acid, and opioids), and IA.</p><p><strong>Conclusions: </strong>We did not find drugs decreasing liability to IA and ASAH but found that antidepressant drugs may increase liability. We observed pleiotropic relationships between IA and other drug classes and indications. Our results improve understanding of pathogenic mechanisms underlying IA.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"687-695"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418413/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139736348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-14DOI: 10.1177/23969873241232311
Yang Zhang, Shuaijie Zhu, Yan Hu, Heng Guo, Jin Zhang, Tianfeng Hua, Zhongheng Zhang, Min Yang
Introduction: Hemorrhagic stroke may cause changes in intracranial pressure (ICP) and cerebral perfusion pressure (CPP), which may influence the prognosis of patients. The aim of this study was to investigate the relationship between early ICP, CPP, and 28-day mortality in the intensive care unit (ICU) of patients with hemorrhagic stroke.
Patients and methods: A retrospective study was performed using the Medical Information Mart for Intensive Care (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), including hemorrhagic stroke patients in the ICU with recorded ICP monitoring. The median values of ICP and CPP were collected for the first 24 h of the patient's monitoring. The primary outcome was 28-day ICU mortality. Multivariable Cox proportional hazards models were used to analyze the relationship between ICP, CPP, and 28-day ICU mortality. Restricted cubic regression splines were used to analyze nonlinear relationships.
Results: The study included 837 patients with a 28-day ICU mortality rate of 19.4%. Multivariable analysis revealed a significant correlation between early ICP and 28-day ICU mortality (HR 1.08, 95% CI 1.04-1.12, p < 0.01), whereas early CPP showed no correlation with 28-day ICU mortality (HR 1.00, 95% CI 0.98-1.01, p = 0.57), with a correlation only evident when CPP < 60 mmHg (HR 1.99, 95% CI 1.14-3.48, p = 0.01). The study also identified an early ICP threshold of 16.5 mmHg.
Discussion and conclusion: Early ICP shows a correlation with 28-day mortality in hemorrhagic stroke patients, with a potential intervention threshold of 16.5 mmHg. In contrast, early CPP showed no correlation with patient prognosis.
{"title":"Correlation between early intracranial pressure and cerebral perfusion pressure with 28-day intensive care unit mortality in patients with hemorrhagic stroke.","authors":"Yang Zhang, Shuaijie Zhu, Yan Hu, Heng Guo, Jin Zhang, Tianfeng Hua, Zhongheng Zhang, Min Yang","doi":"10.1177/23969873241232311","DOIUrl":"10.1177/23969873241232311","url":null,"abstract":"<p><strong>Introduction: </strong>Hemorrhagic stroke may cause changes in intracranial pressure (ICP) and cerebral perfusion pressure (CPP), which may influence the prognosis of patients. The aim of this study was to investigate the relationship between early ICP, CPP, and 28-day mortality in the intensive care unit (ICU) of patients with hemorrhagic stroke.</p><p><strong>Patients and methods: </strong>A retrospective study was performed using the Medical Information Mart for Intensive Care (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), including hemorrhagic stroke patients in the ICU with recorded ICP monitoring. The median values of ICP and CPP were collected for the first 24 h of the patient's monitoring. The primary outcome was 28-day ICU mortality. Multivariable Cox proportional hazards models were used to analyze the relationship between ICP, CPP, and 28-day ICU mortality. Restricted cubic regression splines were used to analyze nonlinear relationships.</p><p><strong>Results: </strong>The study included 837 patients with a 28-day ICU mortality rate of 19.4%. Multivariable analysis revealed a significant correlation between early ICP and 28-day ICU mortality (HR 1.08, 95% CI 1.04-1.12, <i>p</i> < 0.01), whereas early CPP showed no correlation with 28-day ICU mortality (HR 1.00, 95% CI 0.98-1.01, <i>p</i> = 0.57), with a correlation only evident when CPP < 60 mmHg (HR 1.99, 95% CI 1.14-3.48, <i>p</i> = 0.01). The study also identified an early ICP threshold of 16.5 mmHg.</p><p><strong>Discussion and conclusion: </strong>Early ICP shows a correlation with 28-day mortality in hemorrhagic stroke patients, with a potential intervention threshold of 16.5 mmHg. In contrast, early CPP showed no correlation with patient prognosis.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"648-657"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11157555/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139730729","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-01Epub Date: 2024-02-12DOI: 10.1177/23969873241231047
Urs Fischer, Christian Fung, Seraina Beyeler, Lukas Bütikofer, Werner Z'Graggen, Florian Ringel, Jan Gralla, Karl Schaller, Nikolaus Plesnila, Daniel Strbian, Marcel Arnold, Werner Hacke, Peter Jüni, Alexander David Mendelow, Christian Stapf, Rustam Al-Shahi Salman, Jenny Bressan, Stefanie Lerch, Claudio L A Bassetti, Heinrich P Mattle, Andreas Raabe, Jürgen Beck
Rationale: Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown.
Aim: To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone.
Methods and design: SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards.
Sample size: A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test.
Outcomes: The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months.
Discussion: SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone.
理由:减压开颅术(DC)对恶性大脑中动脉梗死患者有益。目的:确定对 ICH 患者进行不清除血肿的减压开颅术加最佳治疗(BMT)与单纯 BMT 相比,是否会降低患者 6 个月后死亡或依赖的风险:SWITCH是一项国际多中心、随机(1:1)、双臂、开放标签、评估者盲法试验。主要纳入标准为:年龄⩽75 岁,因基底节或丘脑 ICH 引起的中风,且 ICH 可能扩展到脑叶、脑室或蛛网膜下腔,格拉斯哥昏迷量表评分 8-13 分,NIHSS 评分 10-30 分,ICH 容量 30-100 毫升。必须进行随机抽样:300名参与者按1:1的比例随机接受DC加BMT治疗与单纯BMT治疗,在双侧α水平为0.05的情况下,使用卡方检验可检测到超过85%的力量,以检测到33%的相对风险降低:主要结果是死亡或依赖的复合结果,定义为 6 个月时修改后的 Rankin 量表评分 5-6 分。次要结果包括 180 天和 12 个月时的死亡、功能状态、生活质量和并发症:SWITCH将使医生了解自发性深部ICH患者接受DC加BMT治疗与单纯BMT治疗的结果:试验注册:ClinicalTrials.gov Identifier:试验注册:ClinicalTrials.gov Identifier:NCT02258919。
{"title":"Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial.","authors":"Urs Fischer, Christian Fung, Seraina Beyeler, Lukas Bütikofer, Werner Z'Graggen, Florian Ringel, Jan Gralla, Karl Schaller, Nikolaus Plesnila, Daniel Strbian, Marcel Arnold, Werner Hacke, Peter Jüni, Alexander David Mendelow, Christian Stapf, Rustam Al-Shahi Salman, Jenny Bressan, Stefanie Lerch, Claudio L A Bassetti, Heinrich P Mattle, Andreas Raabe, Jürgen Beck","doi":"10.1177/23969873241231047","DOIUrl":"10.1177/23969873241231047","url":null,"abstract":"<p><strong>Rationale: </strong>Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown.</p><p><strong>Aim: </strong>To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone.</p><p><strong>Methods and design: </strong>SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards.</p><p><strong>Sample size: </strong>A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test.</p><p><strong>Outcomes: </strong>The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months.</p><p><strong>Discussion: </strong>SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT02258919.</p>","PeriodicalId":46821,"journal":{"name":"European Stroke Journal","volume":" ","pages":"781-788"},"PeriodicalIF":5.8,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11418560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139724502","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}