Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure
: Awad IA, Polster SP, Carrion-Penagos J, Thompson RE, Cao Y, Stadnik A, Money PL, Fam MD, Koskimaki J, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson BA, Mendelow AD, Zuccarello M, Hanley DF, Abdul-Rahim A, Abou-Hamden A, Abraham M, Ahmed A, Alba CA, Aldrich EF, Ali H, Altschul D, Amin-Hanjani S, Anderson CS, Anderson D, Ansari S, Antezana D, Ardelt A, Arikan F, Avadhani R, Baguena M, Baker A, Barrer SJ, Barzo P, Becker KJ, Bergman T, Betz JF, Bistran-Hall AJ, Bostrom A, Braun J, Brindley P, Broaddus WC, Brown R, Buki A, Bulters D, Cao B, Carhuapoma JR, Chalela J, Chang T, Chicoine MR, Chorro IM, Chowdhry S, Cobb C, Corral L, Csiba L, Davies J, Dawson J, Diaz AT, Dierdeyn CP, Diringer M, Dlugash R, Ecker R, Economas T, Enriquez P, Ezer E, Fan YH, Feng H, Franz D, Freeman WD, Fusco M, Galicich W, Gandhi D, Gelea ML, Goldstein J, Gonzalez AC, Grabarits C, Greenberg S, Gregson B, Gress D, Gu E, Gupta G, Hall C, Harnof S, Hernandez FM, Hoesch R, Hoh BL, Houser J, Hu R, Huang J, Huang Y, Hussain MA, Insinga S, Jadhav A, Jaffe J, Jahromi BS, Jallo J, James M, James RF, Janis S, Jankowitz B, Jeon E, Jichici D, Jonczak K, Jonker B, Karlen N, Kase CS, Keric N, Kerz T, Kitagawa R, Knopman J, Koenig C, Krishnamurthy S, Kumar A, Kureshi I, Laidlaw J, Lakhanpal A, Latorre JG, LeDoux D, Lees KR, Leifer D, Leiphart J, Lenington S, Li YK, Lopez G, Lovick D, Lumenta C, Luo JB, Maas MB, MacDonald J, MacKenzie L, Madan V, Majkowski R, Major O, Malhorta R, Malkoff M, Mangat H, Maswadeh A, Matouk C, Mayo SW, McArthur K, McCaul S, Medow J, Mezey G, Mighty J, Miller D, Mitchell P, Mohan KK, Mould WA, Muir K, Munoz L, Nakaji P, Nee A, Nekoovaght-Tak S, Nyquist P, O'Kane R, Okasha M, O'Kelly C, Ostapkovich N, Pandey A, Parry-Jones A, Patel H, Perla KR, Pollack A, Pouratian N, Quinn T, Rajajee V, Reddy K, Rehman M, Reimer R, Rincon F, Rosenblum M, Rybinnik I, Sanchez B, Sansing L, Sarabia R, Schneck M, Schuerer L, Schul D, Schweitzer J, Seder DB, Seyfried D, Sheth K, Spiotta A, Stechison M, Sugar EA, Szabo K, Tamayo G, Tanczos K, Taussky P, Teitelbaum JS, Terry J, Testai F, Thomas K, Thompson CB, Thompson G, Torner JC, Tran H, Tucker K, Ullman N, Ungar L, Unterberg A, Varelas P, Vargas NM, Vatter H, Venkatasubramanian C, Vermillion K, Vespa P, Vollmer D, Wang WM, Wang Y, Wang Y, Wen JJ, Whitworth LT, Willis B, Wilson A, Wolfe S, Wrencher M, Wright SE, Xu YG, Yanase L, Yenokyan G, Yi XX, Yu ZY, Zomorodi A
Publisher: OXFORD UNIV PRESS INC
: 2019
: Neurosurgery
: NEUROSURGERY
: NEUROSURGERY
: 84
: 6
: 1157
: 1167
: 11
: 0148-396X
DOI: https://doi.org/10.1093/neuros/nyz077
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr).OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes.METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n=242) of the MISTIE trial.RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of15 mL end of treatment ICH volume or70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at30 mL end of treatment ICH volume, or>53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation.CONCLUSION This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.
