MD Conference Express ISC 2013 - (Page 19)
Written by Phil Vinall
Paul Vespa, MD, University of California, Los Angeles,
Los Angeles, California, USA, presented 180-day data from
the Intraoperative CT-Guided Endoscopic Surgery trial
[ICES] showing that early CT-guided endoscopic surgery is
safe and associated with improved neurological outcomes
compared with medical management in patients with
primary intracerebral hemorrhage (ICH).
ICES is a substudy of the Minimally Invasive Surgery
Plus rtPA for Intracerebral Hemorrhage Evacuation study
[MISTIE; NCT00224770]. The inclusion and exclusion
criteria for ICES were the same as for MISTIE to facilitate
a prespecified comparison between ICES surgery and
the combined ICES plus MISTIE medical control arm.
Randomization and surgery took place within 48 hours of
stroke onset. Two serial CT scans were performed ≥6 hours
apart to ensure that the hematoma remained stable. The
ICH volume threshold was >20 cc; some intraventricular
hemorrhage was permitted.
Surgery was accomplished using a stereotactic
navigational scan. The endoscope was inserted two thirds of
the way into the hematoma along its long axis, and suction
and then irrigation were applied for variable amounts of
time. The endoscope was backed off to about one third of
the depth, and suction and irrigation were repeated before
the instrument was withdrawn. A postoperative CT scan
was performed. The primary study endpoint was safety.
Secondary endpoints included volume reduction, surgical
serious adverse events, and modified Rankin Scale (mRS)
score at 180 and 365 days.
Subjects (mean age, ~62 years; mostly men) were
randomly assigned to endoscopic surgery (n=18) or
medical management (n=6). Mean time to surgery was
32.8±14 hours. Endoscopic surgery resulted in a 68%±22%
immediate volume reduction (p<0.001; Figure 1) with
the volume being reduced to <15 cc in 67% of patients.
Volume was unchanged in the medically managed patients
after 72 hours. Mortality at 7, 30, and 180 days post onset
was significantly higher in the medical (0%, 7%, and 60%,
respectively) versus the surgical arm (0%, 4%, and 13%,
respectively; p<0.01). One surgical patient had immediate
nonfatal postoperative rebleeding. There was no immediate
surgical-related mortality.
80
p<0.001
70
60
ICH Volume (cc)
Intraoperative CT-Guided
Endoscopic Surgery for ICH [ICES]
Figure 1. Volume Reduction
50
40
68%±22%
reduction
30
20
10
0
Stability Scan
Post-op Scan
Reproduced with permission from P Vespa, MD.
At 180 days, good neurological outcome (mRS score 0
to 3) was more frequent in patients receiving surgery (45%)
compared with those on medical therapy (0%; Figure 2). On
a prespecified intention-to-treat secondary analysis of ICES
surgery versus combined medical controls in ICES plus
MISTIE (n=13 vs n=36) at 180 days, the proportion of mRS
scores 0 to 3 remained 15% greater in ICES surgery versus
combined medical controls (38% vs 23%) [Vespa P et al. ISC
2013 (abstr LB2)].
Figure 2. Functional Outcomes: mRS at Day 180
2
3
4
5
6
n=32
n=6
n=14
MISTIE Medical
100
ICES Medical
ICES Surgical
80
Subjects (%)
embolic stroke mechanism, including those with superficial
vascular distribution, convexity strokes, and strokes of
larger size, providing additional evidence of a biological
effect of closure with the AMPLATZER PFO Occluder.
60
40
20
0
Reproduced with permission from P Vespa, MD.
Official Peer-Reviewed Highlights from International Stroke Conference 2013
19
Table of Contents for the Digital Edition of MD Conference Express ISC 2013
MD Conference Express ISC 2013
Contents
Defending the Stroke Guidelines
Stroke Update: An Overview of What Is Going on in the Area of Stroke
Brain Imaging Does Not Help Identify Patients Who May Benefit From Endovascular Treatments for Acute Ischemic Stroke
MISTIE II Trial: 365-Day Results Demonstrate Improved Outcomes and Cost Benefit
Addition of AMPLATZER PFO Occluder to Medical Therapy Is Beneficial in Patients With Cryptogenic Stroke and PFO
Intraoperative CT-Guided Endoscopic Surgery for ICH [ICES]
The EMBRACE Trial: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients With Cryptogenic Stroke
DP-b99 Does Not Improve Recovery Following Acute Ischemic Stroke
The Secondary Prevention of Small Subcortical Strokes Trial: Blood Pressure Intervention Results
Final Results of the Solitaire FR Thrombectomy for Acute Revascularization: The STAR Trial
Clopidogrel Plus Aspirin Reduces Risk of Recurrent Stroke: The CHANCE Trial
Reversal of Chronic Hypoperfusion to Improve Cognitive Function: The RECON Trial
Cardioembolic Stroke
IMS III
Novel Anticoagulants in Vascular Neurology Practice
Wake-Up Stroke
Virtual Reality in Stroke Rehabilitation
Reward Improves Long-Term Retention of a Motor Memory Through Induction of Offline Memory Gains
MD Conference Express ISC 2013
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