PracticeUpdate Cardiology March 2019

CONFERENCE COVERAGE 22

Minimally Invasive SurgeryMay be Option for Intracranial Hemorrhage Benefits were only seen among patients in whommost of the blood was successfully evacuated. P atients with stable, large intracranial hematoma (ICH) can benefit from minimally invasive surgi- cal evacuation plus alteplase (MISTIE), provided

no effective surgical treatment for ICH, which is the most common type of lethal brain bleed. The proce- dure for MISTIE is to avoid the damage of the traditional craniotomy by using imaging to guide placement of a soft tube into the blood clot through a small hole in the skull to remove large amounts of blood and blood com- ponents.” Dr. Perez-Pinzon is from the Miller School of Medicine at the University of Miami. For the MISTIE III trial, Dr. Hanley and colleagues ran- domized 499 patients with ICH >30 mL from 74 sites to treatment with MISTIE (n=250) or medical therapy (n=249). All patients were randomized 12 to 72 hours after the onset of ICH. This population’s average age was 61 ± 12 years and 61% were male Overall, 62% had basal ganglia and 38% had lobar clot locations. Both groups were similar with respect to age, Glas- gow Coma Scale (GCS) score, clot size, intraventricular extension of intracerebral hemorrhage (IVH) volume, and withdrawal of care. Among the patients randomized to MISTIE, the proto- col-defined surgical goal of reduction of ICH volume to <15 mL, was attained in 59% of patients. In all patients, removal of the hematoma correlated with improved outcome, at P > .001. In addition, the baseline medical good outcome of 42% was higher than the expected rate of 25%. At 365 days, 98% of patients completed follow-up. The rate of pre-specified 30-day mortality was lower for patients treated with MISTIE, compared with medical treatment (9% vs 15%, P = .02). In addition, a mortality difference of 6% to 8% occurred from 30 to 365 days (Kaplan-Meier log-rank, P = .08; adjusted hazard ratio = .70, P = .03 at 365 days) between the two groups, favoring MISTIE. The two groups were similar with respect to rebleeding (3% vs 3%), infection (1% vs 0%), and extended Glasgow outcome scale (eGOS) score (38% vs 34%). However, a per-protocol analysis of patients who attained the surgical goal of ICH volume to <15 mL demonstrated a benefit for MISTIE with respect to both mRS (10%) and eGOS (12%), at P = .01. The per-protocol benefit was independent of race, patient age, exposure to cou- madin or antiplatelet therapy, and duration of surgery. Dr. Hanley pointed out in his presentation that survival rates were modestly improved with MISTIE without the ‘price’ of surgical risk or vegetative state. The procedure can also be safely performed with mini- mal training. Dr. Perez-Pinzon commented that, “When assess- ing the results of surgery for brain hemorrhage, it is critical to consider how much blood was success- fully removed. Unless large majority of clot is in fact removed and only a very small portion of the blood left, the benefits of the surgery will not occur.” www.practiceupdate.com/c/79801

the intervention results in a small residual volume of hematoma, according to a phase III trial presented at ISC 2019. MISTIE is a minimally invasive procedure in which an imaging-guided catheter is used for intracranial clot evacuation in combination with alteplase for the treatment of stable, large ICH. Current evidence and guidelines do not support the use of surgery with craniotomy for the treatment of ICH. A previous meta-analysis, however, suggests there may be poten- tial for MISTIE and that it deserves additional research, according to a presentation given by Daniel F. Han- ley, MD, from Johns Hopkins University in Baltimore. Miguel Perez-Pinzon, PhD, who is chair of International Stroke Conference 2019 ProgramCommittee, provided an online commentary on the MISTIE III trial. In it, he said, “This study is important because there is currently

" This study is important because there is currently no effective surgical treatment for ICH, which is the most common type of lethal brain bleed. "

© AHA/Todd Buchanan 2019

PRACTICEUPDATE CARDIOLOGY