Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment A HERMES Meta-Analysis
Por:
Ng, FC, Yassi, N, Sharma, G, Brown, SB, Goyal, M, Majoie, CBLM, Jovin, TG, Hill, MD, Muir, KW, Saver, JL, Guillemin, F, Demchuk, AM, Menon, BK, San Roman, L, Liebeskind, DS, White, P, Dippel, DWJ, Davalos, A, Bracard, S, Mitchell, PJ, Wald, MJ, Davis, SM, Sheth, KN, Kimberly, WT and Campbell, BCV
Publicada:
1 nov 2021
Ahead of Print:
13 ago 2021
Resumen:
Background and Purpose: Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline. Methods: In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score <= 5. Risk of bias was assessed using the Cochrane tool. Results: Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32-4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66-13.52]) but not MLS (thrombectomy beta=-0.27 [95% CI, -1.52 to 0.98]; reperfusion beta=-0.78 [95% CI, -3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score <= 3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (beta=2.76 [95% CI, 0.33-5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24-12.08]). Conclusions: In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.
Filiaciones:
Ng, FC:
Univ Melbourne, Royal Melbourne Hosp, Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia
Austin Hlth, Dept Neurol, Heidelberg, Germany
Yassi, N:
Univ Melbourne, Royal Melbourne Hosp, Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia
Walter & Eliza Hall Inst Med Res, Populat Hlth & Immun Div, Parkville, Vic, Australia
Sharma, G:
Univ Melbourne, Royal Melbourne Hosp, Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia
Brown, SB:
Altair Biostat, St Louis Pk, MN USA
Goyal, M:
Univ Calgary, Foothills Hosp, Dept Radiol, Calgary, AB, Canada
Majoie, CBLM:
Amsterdam Univ Med Ctr, Dept Radiol & Nucl Med, Locat AMC, Amsterdam, Netherlands
Jovin, TG:
Cooper Univ Hlth Care, Cooper Neurol Inst, Camden, NJ USA
Hill, MD:
Univ Calgary, Foothills Hosp, Dept Clin Neurosci, Hotchkiss Brain Inst,Cumming Sch Med, Calgary, AB, Canada
Muir, KW:
Univ Glasgow, Queen Elizabeth Univ Hosp, Inst Neurosci & Psychol, Glasgow, Lanark, Scotland
Saver, JL:
Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Los Angeles, CA 90095 USA
Univ Calif Los Angeles, David Geffen Sch Med, Comprehens Stroke Ctr, Los Angeles, CA 90095 USA
Stanford Univ, Stanford Stroke Ctr, Stanford, CA 94305 USA
Guillemin, F:
Univ Lorraine, Univ Hosp Nancy, Clin Invest Ctr Clin Epidemiol INSERM 1433, Nancy, France
Demchuk, AM:
Univ Calgary, Foothills Hosp, Dept Clin Neurosci, Hotchkiss Brain Inst,Cumming Sch Med, Calgary, AB, Canada
Menon, BK:
Univ Calgary, Foothills Hosp, Dept Clin Neurosci, Hotchkiss Brain Inst,Cumming Sch Med, Calgary, AB, Canada
San Roman, L:
Hosp Clin Barcelona, Dept Radiol, Barcelona, Spain
Liebeskind, DS:
Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Neurovasc Imaging Res Core, Los Angeles, CA 90095 USA
White, P:
Newcastle Univ, Inst Neurosci, Newcastle Upon Tyne, Tyne & Wear, England
Dippel, DWJ:
Erasmus MC Univ Med Ctr, Dept Neurol, Rotterdam, Netherlands
:
Univ Autonoma Barcelona, Hosp Germans Trias & Pujol, Dept Neurosci, Barcelona, Spain
Bracard, S:
Univ Lorraine, Dept Diagnost & Intervent Neuroradiol, INSERM U947, Nancy, France
Univ Hosp Nancy, Nancy, France
Mitchell, PJ:
Univ Melbourne, Royal Melbourne Hosp, Dept Radiol, Parkville, Vic, Australia
Wald, MJ:
Biogen Inc, 14 Cambridge Ctr, Cambridge, MA 02142 USA
Davis, SM:
Univ Melbourne, Royal Melbourne Hosp, Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia
Sheth, KN:
Yale New Haven Med Ctr, Dept Neurol, 20 York St, New Haven, CT 06504 USA
Kimberly, WT:
Massachusetts Gen Hosp, Dept Neurol, Ctr Genom Med, Boston, MA 02114 USA
Campbell, BCV:
Univ Melbourne, Royal Melbourne Hosp, Melbourne Brain Ctr, Dept Med & Neurol, Parkville, Vic, Australia
Bronze, Green Submitted, Green Accepted
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