Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials.

Background: The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure.

Objective: To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials.

Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials.

Background: Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial.

Objective: To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications.

Suboccipital, Supracerebellar, Infratentorial Approach for Microsurgical Clipping of a Ruptured Tentorial, Straight Sinus Type Dural Arteriovenous Fistula.

Background: Dural arteriovenous fistulas (dAVFs) can often be successfully treated with endovascular embolization; however, surgery is occasionally still required.

Case Description: Herein, we discuss a 65-year-old male patient who presented with a Hunt-Hess IV subarachnoid hemorrhage, intraventricular hemorrhage, and cerebellar intracranial hemorrhage secondary to a ruptured Borden type III tentorial (straight sinus) dAVF. Angiography revealed supply from the left occipital and posterior meningeal arteries and direct drainage into the cerebellar cortical veins with venous aneurysms in both cerebellar hemispheres.

Microsurgery for Unruptured Cerebral Arteriovenous Malformations in the National Inpatient Sample is More Common Post-ARUBA.

Background: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States.

A randomized 500-subject open-label phase 3 clinical trial of minimally invasive surgery plus alteplase in intracerebral hemorrhage evacuation (MISTIE III).

Rationale And Hypothesis: Surgical removal of spontaneous intracerebral hemorrhage may reduce secondary destruction of brain tissue. However, large surgical trials of craniotomy have not demonstrated definitive improvement in clinical outcomes. Minimally invasive surgery may limit surgical tissue injury, and recent evidence supports testing these approaches in large clinical trials.

Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial.

Background: Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage.

Opportunities and challenges in secondary stroke prevention: a mixed methods study.

To describe control of risk factors after stroke from the perspectives of the stroke survivor, the family, and healthcare professionals. A mixed methods design was used, undertaken in two phases: i) qualitative study using focus group methodology to explore secondary stroke prevention and ii) survey of stroke survivors about use of technology and self-management of blood pressure (BP). From the eight focus groups ( = 33), three themes were identified: i) stroke is a wake-up call to do the right things; ii) challenges to doing the right things; and iii) role of technology in helping you to do the right things.

Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial.

Objective: To study factors associated with permanent CSF diversion and the relationship between shunting and functional outcomes in spontaneous intraventricular hemorrhage (IVH).

Methods: Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III), a randomized, multicenter, double-blind, placebo-controlled trial, was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular alteplase improved outcome, in comparison to EVD plus saline. Outcome measures were predictors of shunting and blinded assessment of mortality and modified Rankin Scale at 180 days.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial.

Background: Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

Methods: In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain.

Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial.

Background: Craniotomy, according to the results from trials, does not improve functional outcome after intracerebral haemorrhage. Whether minimally invasive catheter evacuation followed by thrombolysis for clot removal is safe and can achieve a good functional outcome is not known. We investigated the safety and efficacy of alteplase, a recombinant tissue plasminogen activator, in combination with minimally invasive surgery (MIS) in patients with intracerebral haemorrhage.

Older Stroke Patients with High Stroke Scores Have Delayed Door-To-Needle Times.

Introduction: The timely administration of intravenous (IV) tissue plasminogen activator (t-PA) to acute ischemic stroke patients from the period of symptom presentation to treatment, door-to-needle (DTN) time, is an important focus for quality improvement and best clinical practice.

Methods: A retrospective review of our Get With The Guidelines database was performed for a 5-hospital telestroke network for the period between January 2010 and January 2015. All acute ischemic stroke patients who were triaged in the emergency departments connected to the telestroke network and received IV t-PA were included.

Functional Hemispherectomy for Refractory Status Epilepticus in 2 Adults.

Background: Status epilepticus (SE) is a medical emergency, as deleterious long-term effects are well known. Medically induced burst suppression is often required if first-line and second-line treatments fail. Surgical intervention can be considered in some patients after prolonged treatment failure of medically induced coma.

Cannabis Use and Outcomes in Patients With Aneurysmal Subarachnoid Hemorrhage.

Background And Purpose: The incidence of cannabis use in patients with aneurysmal subarachnoid hemorrhage (aSAH) and its impact on morbidity, mortality, and outcomes are unknown. Our objective was to evaluate the relationship between cannabis use and outcomes in patients with aSAH.

Methods: Records of consecutive patients admitted with aSAH between 2010 and 2015 were reviewed.

Early Hypoalbuminemia is an Independent Predictor of Mortality in Aneurysmal Subarachnoid Hemorrhage.

Background: Hypoalbuminemia has been identified as a predictor of morbidity and mortality in critically ill patients. There is very little data on the significance and the prognostic value of hypoalbuminemia in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study analyzed the impact of hypoalbuminemia on patient presentation, complications, and outcomes.

Proximal subcutaneous migration of the distal end of a ventriculoperitoneal shunt presenting with recurrent cerebrospinal fluid galactorrhea.

The authors report an unusual case of recurrent proximal migration of the distal end of a ventriculoperitoneal shunt catheter presenting as CSF galactorrhea. The authors review the pertinent literature and discuss the possible causes as well as techniques to prevent a similar occurrence.

Delayed post-traumatic spinal cord infarction in an adult after minor head and neck trauma: a case report.

Introduction: Delayed post-traumatic spinal cord infarction is a devastating complication described in children. In adults, spinal cord ischemia after cardiovascular interventions, scoliosis correction, or profound hypotension has been reported in the literature. However, delayed spinal cord infarction after minor head trauma has not been described yet.

Baboon model of generalized epilepsy: continuous intracranial video-EEG monitoring with subdural electrodes.

The baboon provides a natural non-human primate model for photosensitive, generalized epilepsy. This study describes an implantation procedure for the placement of subdural grid and strip electrodes for continuous video-EEG monitoring in the epileptic baboon to evaluate the generation and propagation of ictal and interictal epileptic discharges. Subdural grid, strip and depth electrodes were implanted in six baboons, targeting brain regions that were activated in functional neuroimaging studies during photoparoxysmal responses.

Early progression of traumatic cerebral contusions: characterization and risk factors.

Background: Traumatic intracerebral contusions carry a high rate of early progression and are associated with morbidity and mortality. Our objectives were to better characterize the prevalence of progression of traumatic contusions, risk factors, and the association with outcome.

Methods: Participants were 46 patients with traumatic intracerebral contusion who underwent a repeat computed tomography (CT) scan within 24 hours of injury.