Clot evacuation reduces perihematomal edema in hemorrhagic stroke

Minimally invasive surgery combined with recombinant tissue-type plasminogen activator (rt-PA) significantly reduces perihematomal edema (PHE) in patients with intracerebral hemorrhage (ICH).

The finding, published in Stroke, comes from an analysis of the minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II trial, which tested safety and efficacy of hematoma evacuation after ICH. MISTIE II enrolled 118 patients (79 surgical and 39 medical) in a multicenter, randomized, prospective trial with the aim of testing image-guided catheter-based blood clot removal in patients with hypertensive ICH. The trial entailed dose finding and safety stages to determine an optimal combination of minimally invasive surgery with rt-PA administration.

The current study was a semiautomated, computerized volumetric analysis of computed tomography scans from MISTIE II patients, to assess the impact of both hematoma removal and rt-PA on PHE. By doing so, the research team could assess whether hematoma removal with minimally invasive surgery and rt-PA would result in a greater reduction in edema volume at the end of treatment relative to standard medical care.

"Our analysis… is consistent with the hypothesis that successful hematoma evacuation leads to significant edema volume reduction," write Juan Ricardo Carhuapoma (Johns Hopkins Medical Institutions, Baltimore, Maryland, USA) and colleagues. "This is the first time such an observation is confirmed in a prospectively obtained cohort of ICH patients."

The surgical cohort was found to have a mean hematoma volume at the end of treatment of 19.6 cm3, which was significantly smaller than the medical cohort's mean volume of 40.7 cm3. Edema volume at the end of treatment was also significantly lower in the surgical cohort (27.7 cm3) than the medical cohort (41.7 cm3).

Within the surgical cohort, those who received rt-PA in addition to surgical aspiration (n=69) had a clot reduction that was similar to the patients who only underwent surgical aspiration (n=10), at 18.9 and 24.5 cm3, respectively.

A significant graded effect on change in size of PHE was observed depending on degree of ICH removal; clot removal of over 65% was associated with a mean PHE reduction of 10.7 cm3 while clot removal below 20% showed a mean increase in PHE of 11.4 cm3.

"This is the most promising treatment that has come along in the last 30 or 40 years for people who have suffered hemorrhagic stroke," study co-author Daniel Hanley (also from Johns Hopkins School of Medicine) said in a press release, describing the procedure as "technically simple" and having the potential to be widely adopted.

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