Nauman Tariq

Effect of Systolic Blood Pressure Reduction on Hematoma Expansion, Perihematomal Edema, and 3-Month Outcome Among Patients With Intracerebral Hemorrhage: Results From the Antihypertensive Treatment of Acute Cerebral Hemorrhage Study

BACKGROUND Evidence indicates that systolic blood pressure (SBP) reduction may reduce hematoma expansion in patients with intracerebral hemorrhage (ICH) who are initially seen with acute hypertensive response. OBJECTIVE To explore the relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema, and 3-month outcome among patients with ICH. DESIGN Post hoc analysis of a traditional phase 1 dose-escalation multicenter prospective study. SETTING Emergency departments and intensive care units. PATIENTS Patients having ICH with an elevated SBP of at least 170 mm Hg who were seen within 6 hours of symptom onset. INTERVENTION Systolic blood pressure reduction using intravenous nicardipine hydrochloride targeting 3 tiers of sequentially escalating SBP reduction goals (170-199, 140-169, or 110-139 mm Hg). MAIN OUTCOME MEASURES We evaluated the effect of SBP reduction (relative to initial SBP) on the following: hematoma expansion (defined as an increased intraparenchymal hemorrhage volume >33% on 24-hour vs baseline computed tomographic [CT] images), higher perihematomal edema ratio (defined as a >40% increased ratio of edema volume to hematoma volume on 24-hour vs baseline CT images), and poor 3-month outcome (defined as a modified Rankin scale score of 4-6). RESULTS Sixty patients (mean [SD] age, 62.0 [15.1] years; 34 men) were recruited (18, 20, and 22 patients in each of the 3 SBP reduction goal tiers). The median area under the curve (AUC) (calculated as the area between the hourly SBP measurements over 24 hours and the baseline SBP) was 1360 (minimum, 3643; maximum, 45) U. Comparing patients having less vs more aggressive SBP reduction based on 24-hour AUC analysis, frequencies were 32% vs 17% for hematoma expansion, 61% vs 40% for higher perihematomal edema ratio, and 46% vs 38% for poor 3-month outcome (P > .05 for all). The median SBP reductions were 54 mm Hg at 6 hours and 62 mm Hg at 6 hours from treatment initiation. Comparing patients having equal to or less vs more than the median SBP reduction at 2 hours, frequencies were 21% vs 31% for hematoma expansion, 42% vs 57% for higher perihematomal edema ratio, and 35% vs 48% for poor 3-month outcome (P > .05 for all). CONCLUSIONS We found no significant relationship between SBP reduction and any of the outcomes measured herein; however, the Antihypertensive Treatment of Acute Cerebral Hemorrhage study was primarily a safety study and was not powered for such end points. The consistent favorable direction of these associations supports further studies with an adequately powered randomized controlled design to evaluate the efficacy of aggressive pharmacologic SBP reduction.

Occurrence and Predictors of Futile Recanalization following Endovascular Treatment among Patients with Acute Ischemic Stroke: A Multicenter Study

BACKGROUND AND PURPOSE: Although recanalization is the goal of thrombolysis, it is well recognized that it fails to improve outcome of acute stroke in a subset of patients. Our aim was to assess the rate of and factors associated with “futile recanalization,” defined by absence of clinical benefit from recanalization, following endovascular treatment of acute ischemic stroke. MATERIALS AND METHODS: Data from 6 studies of acute ischemic stroke treated with mechanical and/or pharmacologic endovascular treatment were analyzed. “Futile recanalization” was defined by the occurrence of unfavorable outcome (mRS score of ≥3 at 1–3 months) despite complete angiographic recanalization (Qureshi grade 0 or TIMI grade 3). RESULTS: Complete recanalization was observed in 96 of 270 patients treated with IA thrombolysis. Futile recanalization was observed in 47 (49%). In univariate analysis, patients with futile recanalization were older (73 ± 11 versus 58 ± 15 years, P < .0001) and had higher median initial NIHSS scores (19 versus 14, P < .0001), more frequent BA occlusion (17% versus 4%, P = .049), less frequent MCA occlusion (53% versus 76%, P = .032), and a nonsignificantly higher rate of symptomatic hemorrhagic complications (2% versus 9%, P = .2). In logistic regression analysis, futile recanalization was positively associated with age >70 years (OR, 4.4; 95% CI, 1.9–10.5; P = .0008) and initial NIHSS score 10–19 (OR, 3.8; 95% CI, 1.7–8.4; P = .001), and initial NIHSS score ≥20 (OR, 64.4; 95% CI, 28.8–144; P < .0001). CONCLUSIONS: Futile recanalization is a relatively common occurrence following endovascular treatment, particularly among elderly patients and those with severe neurologic deficits.

Impact of International Subarachnoid Aneurysm Trial results on treatment of ruptured intracranial aneurysms in the United States: Clinical article

OBJECT The utilization of endovascular treatment for ruptured intracranial aneurysms is expected to change since the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. The authors performed this analysis to determine the impact of ISAT results on treatment selection for ruptured intracranial aneurysms and associated in-hospital outcomes using nationally representative data. METHODS We determined the national estimates of treatments used for ruptured intracranial aneurysms and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. All the variables pertaining to hospitalization were compared between 2000-2002 and 2004-2006, and in-hospital outcomes were analyzed using multivariate analysis. RESULTS In the 3-year periods prior to and after the ISAT, there were 70,637 and 77,352 admissions for ruptured intracranial aneurysms, respectively. There was a significant increase in endovascular treatment after publication of the ISAT (trend test, p < 0.0001) The in-hospital mortality for ruptured intracranial aneurysm admissions decreased from 27% to 24% (odds ratio [OR] 0.89, 95% CI 0.83-0.96, p = 0.003) after the publication of the ISAT. The cost of hospitalization after adjusting for procedures practices was not significantly higher after the publication of the ISAT (

Balloon Angioplasty for Intracranial Atherosclerotic Disease: Periprocedural Risks and Short-Term Outcomes in a Multicenter Study

21,437 vs

Reliability of Hematoma Volume Measurement at Local Sites in a Multicenter Acute Intracerebral Hemorrhage Clinical Trial

22,817, p < 0.89), but cost of hospitalization was higher in the post-ISAT period for patients undergoing endovascular procedure. CONCLUSIONS The results of the ISAT have been associated with a prominent change in practice patterns related to the treatment of ruptured aneurysms. The cost of hospitalization has increased and the mortality has decreased, presumably due to a larger proportion of patients receiving any treatment and endovascular treatment.

Outcomes of Thrombolytic Treatment for Acute Ischemic Stroke in Dialysis-Dependent Patients in the United States

Background and Purpose— Whether stenting is superior to angioplasty in the treatment of intracranial atherosclerotic disease is unknown. Dissections, vessel rupture, and lesion recoil observed with primary angioplasty using balloon catheters designed for coronary arteries have undermined the role of primary angioplasty as a preferred treatment for intracranial atherosclerotic disease. The goal of this study is to report the immediate and 3-month outcomes of treating patients with intracranial atherosclerotic disease with angioplasty balloon catheters in a multicenter study. Methods— This is a retrospective review of 74 patients from 4 institutions treated with primary angioplasty for intracranial atherosclerotic disease over a 6-year time period. Technical success (residual stenosis ≤50%), periprocedural success (no vascular complication within 72 hours), and 3-month outcomes are reported. Results— The mean degree of stenosis pretreatment was 79%±14% and reduced to 34%±18% after angioplasty. Technical success was achieved in 68 (92%; 95% CI, 83% to 97%) of the 74 patients. Periprocedural success was achieved in 65 (88%; 95% CI, 78% to 94%) of the 74 patients. There were 4 (5%; 95% CI, 1.5% to 13%) major procedure-related strokes, 2 of which resulted in death within 6 hours of the procedure. The 30-day stroke/death rate was 5% (4 of 74; CI, 1.5% to 13%). Three-month follow-up was available in 71 patients. In this interval, 2 patients had new stroke, 1 in the ipsilateral territory and the other in the contralateral territory. The 3-month stroke or death rate was 8.5% (6 of 71; CI, 3.1% to 17.5%); the retreatment rate was 2.8% (2 of 71; CI, 0.3% to 10%). Conclusion— Balloon angioplasty is a relatively safe alternative treatment for intracranial atherosclerotic disease. Its role in the long-term secondary prevention of recurrent stroke as compared with intracranial stenting and medical therapy remains to be determined, preferably in a randomized study.

Systolic Blood Pressure Reduction and Risk of Acute Renal Injury in Patients with Intracerebral Hemorrhage

Background and Purpose— The reliability of hematoma volume (HV) measurement using the ABC/2 method in multicenter clinical trials is unknown. We determined the accuracy of ABC/2 method as an on-site test in comparison with the gold standard central HV-assessment and semiautomatic HV-assessment. Method— We analyzed data from an acute intracerebral hemorrhage multicenter clinical trial. HV was measured by site investigators to determine enrollment eligibility (<60 cm3) using the ABC/2 method (on-site HV), and independently by the core-imaging laboratory using computer-based analysis (Medical Image Processing, Analysis, and Visualization [MIPAV] HV). HV was also measured by ABC/2 method (central HV) at the core-imaging laboratory to assess the difference in measurements between on-site (multiple raters with variable experiences) and central (single experienced rater) HVs. Results— Fifty-six subjects were analyzed (mean age 62±15 years; 45% women). On-site HV values showed a significantly lower correlation with the MIPAV HV (r=0.63) than central HV and MIPAV HV (r=0.93) values. The correlation between on-site HV and central HV values was modest (r=0.51). A total of 73% of the central HVs were within 25% of the corresponding MIPAV HVs, whereas only 46% of the on-site HVs were within 25% of the corresponding MIPAV HVs (P<0.001). One protocol violation occurred as a result of inaccuracy of on-site HV measurement. Conclusion— On-site HV measurements showed high variability, but the impact on the eligibility determination was small. Centralized remeasurements of HVs with feedback to the sites may increase the reliability of the on-site HV measurements. Clinical Trial Registration— URL: http://www.clinicaltrials.gov/ct2/show/NCT00415610 or http://www.atach-2.com. Unique identifier: NCT00415610.

Intra‐Arterial Tenecteplase for Treatment of Acute Ischemic Stroke: Feasibility and Comparative Outcomes

OBJECTIVE To determine the outcomes of dialysis-dependent renal failure patients who had ischemic stroke and were treated with intravenous (IV) thrombolytics in the United States. METHODS We analyzed the data from Nationwide Inpatient Sample (2002-2009) for all thrombolytic-treated patients presenting with acute ischemic stroke with or without dialysis dependence. Patients were identified using the International Classification of Disease, Ninth Revision, Clinical Modification codes. Baseline characteristics, in-hospital complications including secondary intracerebral hemorrhage (ICH), sepsis, pneumonia, pulmonary embolism, deep venous thrombosis, urinary tract infections, and discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the groups. RESULTS Of the 82,142 patients with ischemic stroke who receive thrombolytic treatment, 1072 (1.3%) was dialysis dependent. The ICH rates did not differ significantly between patients with ischemic stroke with or without dialysis who received thrombolytics (5.2% versus 6.1%). The in-hospital mortality rate was higher in dialysis-dependent patients treated with thrombolytics (22% versus 11%, P≤.0001). After adjusting for age, sex, and comorbidities, dialysis dependence was associated with higher rates of in-hospital mortality in patients treated with thrombolytics (odds ratio, 1.92; 95% confidence interval, 1.33-2.78, P=.0005). CONCLUSIONS The 2-fold higher odds of in-hospital mortality associated with administration of IV thrombolytics in dialysis-dependent patients who present with acute ischemic stroke warrant a careful assessment of risk-benefit ratio in this population.

Predictors and Timing of Neurological Complications Following Intracranial Angioplasty and/or Stent Placement

BACKGROUND Aggressive systolic blood pressure reduction may precipitate acute renal injury because of underlying hypertensive nephropathy in patients with intracerebral hemorrhage. The studys objective was to determine the rate and determinants of acute renal injury during acute hospitalization among subjects with intracerebral hemorrhage using a post hoc analysis of a multicenter prospective study. METHODS Subjects with intracerebral hemorrhage and elevated systolic blood pressure of 170 mm Hg or greater who presented within 6 hours of symptom onset and underwent treatment of acute hypertensive response and fluid management as per study and local protocols, respectively. Acute renal injury was defined post hoc using the criteria used in Acute Kidney Injury Network classifications within 72 hours of admission. Descriptive statistics and standard statistical tests were used to characterize and evaluate the effect of systolic blood pressure reduction parameters (relative to initial systolic blood pressure) and average maximum hourly dose of nicardipine on the occurrence of acute renal injury. RESULTS A total of 60 subjects were recruited (57% were men; mean age of 62.0 ± 15.1 years). Five subjects (9%) had stage I acute renal injury according to the Acute Kidney Injury Network criteria. None of the subjects had stage II or III acute renal injury. The serum creatinine course for the first 3 days suggested that the peak elevation of creatinine was seen at 18, 30, 57, 58, and 71 hours after baseline measurements in these 5 subjects, all of which except for the first one were beyond the protocol-specified treatment period. The incidences of neurologic deterioration and symptomatic hematoma expansion were significantly greater in the subjects with stage I renal impairment. The systolic blood pressure reduction parameters (in particular, the area under the curve depicting the 24-hour systolic blood pressure summary statistic) and the higher average maximum hourly nicardipine dose were strongly associated with stage I renal impairment. CONCLUSIONS Although acute renal injury is infrequent and mild among subjects with intracerebral hemorrhage undergoing systolic blood pressure reduction, a trend in association between systolic blood pressure reduction and renal impairment was observed in this small study. Therefore, it is important to carefully monitor the renal function when administering treatment to reduce systolic blood pressure in patients with intracerebral hemorrhage.

Determinants of Neurologic Deterioration and Stroke-Free Survival After Spontaneous Cervicocranial Dissections: A Multicenter Study

Tenecteplase (TNK) is a third‐generation thrombolytic agent. We evaluated the safety and feasibility of intra‐arterial (IA) administration of TNK in patients with acute ischemic stroke.