MD Conference Express ISC 2013 - (Page 17)
Figure 1. Functional Outcomes
0
100
2
n=38
3
4
5
6
365-Day mRS
n=52
n=25
n=23
80
14%
11%
60
21%
LTCF
8%
40
MISTIE II Trial: 365-Day Results
Demonstrate Improved Outcomes
and Cost Benefit
20
0
Medical
Written by Phil Vinall
Surgical
Medical
180-Day Outcomes
Surgical
365-Day Outcomes
LTCF=long-term care facility; mRS=modified Rankin Scale.
Reproduced with permission from D Hanley, MD.
Figure 2. Functional Improvements: Stroke Impact Scale
MIS+rtPA
Medical Management
Mobility
100
ADL
100
80
Stroke Impact Scale: ADL Score
Stroke Impact Scale: Mobility Score
Daniel Hanley, MD, Johns Hopkins University, Baltimore,
Maryland, USA, presented results from the Minimally
Invasive Surgery Plus tPA for Intracerebral Hemorrhage
Evacuation trial [MISTIE; NCT00224770], which showed
that catheter-based clot reduction plus tissue plasminogen
activator (MIS + tPA) is safe and may reduce long-term
disability after intracerebral hemorrhage.
Volume of intracerebral hemorrhage (ICH) is the
strongest predictor of 30-day outcome for all locations of
spontaneous ICH [Broderick JP et al. Stroke 1993]. MISTIE
was a 2-stage multicenter, Phase 2 trial that examined
outcomes and cost benefit of reducing clot size by using a
catheter inserted into the largest part of the clot to apply tPA
every 8 hours for 3 days. The study included patients with
spontaneous supratentorial ICH ≥20 cc (stable ≥6 hours post
diagnosis as shown on computed tomography) who were
treated with either MIS plus tPA (n=54) or standard medical
care (n=42) and followed for 180 days for stage I and 365 days
for stage II. Participants were mean age 61 years (55.2% white,
65.6% men). Most were hypertensive (86.5%) and 26.5% had
a diagnosis of diabetes. Prior smokers were more common
in the surgical group (31.5%) versus those receiving standard
medical therapy (7.1%). Of the subjects, 75% received their
surgery between 12 and 38 hours post event.
At 365 days there was a 14% difference in functional
performance (defined as 0 to 3 vs 4 to 6 on the modified
Rankin Scale [mRS]) favoring MIS plus tPA (slightly
greater than the 11% difference observed at 180 days).
The improvement included a differential shift to higher
independence levels at mRS 0 to 2 (Figure 1). Similar
magnitudes of improvement (Figure 2) were also seen when
the subjects were evaluated for improvements in mobility
and activities of daily living using the Stroke Impact Scale
[Duncan PW et al. Stroke 1999].
1
180-Day mRS
Subjects (%)
The study also found no superior benefit with
embolectomy over standard care based on imaging
pattern. Outcomes of embolectomy and standard
care were a mean 90-day mRS score of 3.9 versus 3.4,
respectively (p=0.23), for patients with a favorable
penumbral pattern and a mean score of 4.0 versus 4.4,
respectively (p=0.38), for patients with a nonpenumbral
pattern. According to Dr. Kidwell, the study underscores
the importance of confirming hypotheses in randomized,
controlled trials prior to implementing treatment
approaches in clinical practice.
60
40
20
80
60
40
20
0
0
0 30
90
180
270
Time Post Stroke (Days)
365
0 30
90
180
270
Time Post Stroke (Days)
365
ADL=activities of daily living; MIS=minimally invasive surgery; rtPA=recombinant tissue
plasminogen activator.
Reproduced with permission from D Hanley, MD.
The improvements were also reflected in the cost of care.
Although the median length of intensive care unit (ICU) stay
was similar for both groups (9 days for patients in the surgical
group vs 8 days for patients in the standard medical therapy
group) the median hospital stay was 38 days shorter for the
MIS plus tPA group (p=0.015). In addition, fewer surgical
patients were residing in long-term care facilities both at 180
(17% vs 24%; not significant) and 365 days (8% vs 21%; not
significant). After accounting for all costs (eg, ICU stay, MIS
+ tPA procedures), the results indicate that the experimental
procedure saves an estimated $44,329 of medical care costs
per patient [Hanley DF et al. ISC 2013 (abstr LB1)].
Official Peer-Reviewed Highlights from International Stroke Conference 2013
17
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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