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Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial

  • Conference paper
Book cover Cerebral Hemorrhage

Part of the book series: Acta Neurochirurgica Supplementum ((NEUROCHIRURGICA,volume 105))

Abstract

Introduction

Compared to ischemic stroke, intracerebral hemorrhage (ICH) is easily and rapidly identified, occurs in younger patients, and produces relatively small initial injury to cerebral tissues - all factors suggesting that interventional amelioration is possible. Investigations from the last decade established that extent of ICH-mediated brain injury relates directly to blood clot volume and duration of blood exposure to brain tissue. Using minimally-invasive surgery plus recombinant tissue plasminogen activator (rtPA), MISTIE investigators explored aggressive avenues to treat ICH.

Methods

We investigated the difference between surgical intervention plus rtPA and standard medical management for ICH. Subjects in both groups were medically managed according to standard ICU protocols. Subjects randomized to surgery underwent ste-reotactic catheter placement and clot aspiration. Injections of rtPA were then given through hematoma catheter every 8 h, up to 9 doses, or until a clot-reduction endpoint. After each injection the system was flushed with sterile saline and closed for 60 min before opening to spontaneous drainage.

Results

Average aspiration of clots for all patients randomized to surgery plus rtPA was 20% of mean initial clot size. After acute treatment phase (aspiration plus rtPA), clot was reduced an average of 46%. Recorded adverse events were within safety limits, including 30-day mortality, 8%; symptomatic re-bleeding, 8%; and bacterial ventriculitis, 0%. Patients randomized to medical management showed 4% clot resolution in a similar time window. Preliminary analysis indicates that clot resolution rates are greatly dependent on catheter placement. Location of ICH also affects efficacy of aggressive treatment of ICH.

Conclusion

There is tentative indication that minimally-invasive surgery plus rtPA shows greater clot resolution than traditional medical management.

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References

  1. Abdul-Ghaffar NU, el-Sonbaty MR, el-Din Abdul-Baky MS, Marafie AA, al-Said AM (1997) Stroke in Kuwait: a three-year prospective study. Neuroepidemiology 16: 40–47

    Article  PubMed  CAS  Google Scholar 

  2. Akdemir H, Selçuklu A, Pasaoĝlu A, Oktem IS, Kavuncu I (1995) Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase. Neurosurg Rev 18: 95–100

    Article  PubMed  CAS  Google Scholar 

  3. Becker KJ, Baxter AB, Bybee HM, Tirschwell DL, Abouelsaad T, Cohen WA (1999) Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 30: 2025–2032

    PubMed  CAS  Google Scholar 

  4. Broderick JP, Brott T, Tomsick T, Miller R, Huster G (1993) Intracerebral hemorrhage more than twice as common as subarach-noid hemorrhage. J Neurosurg 78: 188–191

    PubMed  CAS  Google Scholar 

  5. Brown RD Jr, Ransom J, Hass S, Petty GW, O’Fallon WM, Whisnant JP, Leibson CL (1999) Use of nursing home after stroke and dependence on stroke severity: a population-based analysis. Stroke 30: 924–929

    PubMed  Google Scholar 

  6. Caplan LR (1992) Intracerebral hemorrhage. Lancet 339: 656–658

    Article  PubMed  CAS  Google Scholar 

  7. Daverat P, Castel JP, Dartigues JF, Orgogozo JM (1991) Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke 22: 1–6

    PubMed  CAS  Google Scholar 

  8. Findlay JM, Weir BK, Kassell NF, Disney LB, Grace MG (1991) Intracisternal recombinant tissue plasminogen activator after aneurysmal subarachnoid hemorrhage. J Neurosurg 75: 181–188

    PubMed  CAS  Google Scholar 

  9. Findlay JM, Grace MG, Weir BK (1993) Treatment of intraventricular hemorrhage with tissue plasminogen activator. Neurosurgery 32: 941–947

    Article  PubMed  CAS  Google Scholar 

  10. Hondo H, Uno M, Sasaki K Ebisudani D, Shichijo F, Tóth Z, Matsumoto K (1990) Computed tomography controlled aspiration surgery for hypertensive intracerebral hemorrhage. Experience of more than 400 cases. Stereotact Funct Neurosurg 54-55: 432–437

    Article  PubMed  CAS  Google Scholar 

  11. Kandel EI, Peresedov VV (1985) Stereotaxic evacuation of spontaneous intracerebral hematomas. J Neurosurg 62: 206–213

    PubMed  CAS  Google Scholar 

  12. Kumral E, Ozkaya B, Sagduyu A, Sirin H, Vardarli E, Pehlivan M (1998) The EGE stroke registry: a hospital-based study in the Aegean region, Izmir, Turkey. Analysis of 2000 stroke patients. Cerebrovasc Dis 8: 278–288

    Article  PubMed  CAS  Google Scholar 

  13. Lampl Y, Gilad R, Eshel Y, Sarova-Pinhas I (1995) Neurological and functional outcome in patients with supratentorial hemorrhages. A prospective study. Stroke 26: 2249–2253

    PubMed  CAS  Google Scholar 

  14. Lippitz BE, Mayfrank L, Spetzger U, Warnke JP, Bertalanffy H, Gilsbach JM (1994) Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results. Acta Neurochir (Wien) 127: 157–160

    Article  CAS  Google Scholar 

  15. Matsumoto K, Hondo H (1984) CT-guided stereotaxic evacuation of hypertensive intracerebral hematomas. J Neurosurg 61: 440–448

    Article  PubMed  CAS  Google Scholar 

  16. Mayfrank L, Lippitz B, Groth M, Bertalanffy H, Gilsbach JM (1993) Effect of recombinant tissue plasminogen activator on clot lysis and ventricular dilatation in the treatment of severe intraventricular haemorrhage. Acta Neurochir (Wien) 122: 32–38

    Article  CAS  Google Scholar 

  17. Miller DW, Barnett GH, Kormos DW, Steiner CP (1993) Stereo-tactically guided thrombolysis of deep cerebral hemorrhage: preliminary results. Cleve Clin J Med 60: 321–324

    PubMed  CAS  Google Scholar 

  18. Mohadjer M, Braus DF, Myers A, Scheremet R, Krauss JK (1992) CT-stereotactic fibrinolysis of spontaneous intracerebral hemato-mas. Neurosurg Rev 15: 105–110

    Article  PubMed  CAS  Google Scholar 

  19. Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC (1998) Surgical treatment for intracerebral hemorrhage (STICH): a single-center, randomized clinical trial. Neurology 51: 1359–1363

    PubMed  CAS  Google Scholar 

  20. Ojemann RG, Heros RC (1983) Spontaneous brain hemorrhage. Stroke 14: 468–475

    PubMed  CAS  Google Scholar 

  21. Rohde V, Schaller C, Hassler WE (1995) Intraventricular recombinant tissue plasminogen activator for lysis of intraventricular haemorrhage. J Neurol Neurosurg Psychiatry 58: 447–451

    Article  PubMed  CAS  Google Scholar 

  22. Schaller C, Rohde V, Meyer B, Hassler W (1995) Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator. Neurosurgery 36: 328–335

    Article  PubMed  CAS  Google Scholar 

  23. Shen PH, Matsuoka Y, Kawajiri K, Kanai M, Hoda K, Yamamoto S, Nishimura S (1990) Treatment of intraventricular hemorrhage using urokinase. Neurol Med Chir (Tokyo) 30: 329–333

    Article  CAS  Google Scholar 

  24. Todo T, Usui M, Takakura K (1991) Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase. J Neurosurg 74: 81–86

    PubMed  CAS  Google Scholar 

  25. Tzaan WC, Lee ST, Lui TN (1997) Combined use of stereotactic aspiration and intracerebral streptokinase infusion in the surgical treatment of hypertensive intracerebral hemorrhage. J Formos Med Assoc 96: 962–967

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Johns Hopkins University, Baltimore, 1550 Orleans Street, CRB II 3M50 South, MD, 21231, USA

    T. Morgan BSc, P. Keyl, K. Lane & D. Hanley

  2. University of Cincinnati, Cincinnati, OH, USA

    M. Zuccarello & R. Narayan

Authors
  1. T. Morgan BSc
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  2. M. Zuccarello
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  3. R. Narayan
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  4. P. Keyl
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  5. K. Lane
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  6. D. Hanley
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Editor information

Editors and Affiliations

  1. Department of Neurosurgery, School of Medicine, Huashan Hospital, Fudan University, Shanghai, China

    Liang-Fu Zhou , Xian-Cheng Chen  & Feng-Ping Huang ,  & 

  2. Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA

    Guohua Xi , Richard F. Keep , Ya Hua  & Karin Muraszko , ,  & 

  3. Department of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China

    Yi-Cheng Lu

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© 2008 Springer-Verlag

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Morgan, T., Zuccarello, M., Narayan, R., Keyl, P., Lane, K., Hanley, D. (2008). Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. In: Zhou, LF., et al. Cerebral Hemorrhage. Acta Neurochirurgica Supplementum, vol 105. Springer, Vienna. https://doi.org/10.1007/978-3-211-09469-3_30

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  • DOI: https://doi.org/10.1007/978-3-211-09469-3_30

  • Publisher Name: Springer, Vienna

  • Print ISBN: 978-3-211-09468-6

  • Online ISBN: 978-3-211-09469-3

  • eBook Packages: MedicineMedicine (R0)

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