Cerebral small vessel disease modifies outcomes after minimally invasive surgery for intracerebral haemorrhage

• Published in: Stroke and vascular neurology Vol. 9; no. 4; pp. 446 - 456
• Main Authors: Li, Yunke, Cho, Sung-Min, Avadhani, Radhika, Ali, Hassan, Hao, Yi, Murthy, Santosh B, Goldstein, Joshua N, Xia, Fan, Hu, Xin, Ullman, Natalie L, Awad, Issam, Hanley, Daniel, Ziai, Wendy C
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 01.08.2024; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Aged; Cerebral Hemorrhage - diagnostic imaging; Cerebral Hemorrhage - surgery; Cerebral Small Vessel Diseases - diagnostic imaging; Cerebral Small Vessel Diseases - physiopathology; Cerebral Small Vessel Diseases - surgery; Clinical Trial; Clinical trials; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - adverse effects; Functional Status; Hemorrhage; Humans; Laparoscopy; Magnetic Resonance Imaging; Male; Medical imaging; Middle Aged; Minimally invasive surgery; Minimally Invasive Surgical Procedures; Neuroimaging; Neurosurgical Procedures - adverse effects; Original Research; Patients; Predictive Value of Tests; Recovery of Function; Risk Assessment; Risk Factors; Stroke; Surgery; Thrombolytic drugs; Thrombolytic Therapy - adverse effects; Time Factors; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - adverse effects; Treatment Outcome; Clinical Trial; Magnetic Resonance Imaging; Stroke
• ISSN: 2059-8688; 2059-8696; 2059-8696
• DOI: 10.1136/svn-2023-002463

BackgroundMinimally invasive surgery (MIS) for spontaneous supratentorial intracerebral haemorrhage (ICH) is controversial but may be beneficial if end-of-treatment (EOT) haematoma volume is reduced to ≤15 mL. We explored whether MRI findings of cerebral small vessel disease (CSVD) modify the effect of MIS on long-term outcomes.MethodsPrespecified blinded subgroup analysis of 288 subjects with qualified imaging sequences from the phase 3 Minimally Invasive Surgery Plus Alteplase for Intracerebral Haemorrhage Evacuation (MISTIE) trial. We tested for heterogeneity in the effects of MIS and MIS+EOT volume ≤15 mL on the trial’s primary outcome of good versus poor function at 1 year by the presence of single CSVD features and CSVD scores using multivariable models.ResultsOf 499 patients enrolled in MISTIE III, 288 patients had MRI, 149 (51.7%) randomised to MIS and 139 (48.3%) to standard medical care (SMC). Median (IQR) ICH volume was 42 (30–53) mL. In the full MRI cohort, there was no statistically significant heterogeneity in the effects of MIS versus SMC on 1-year outcomes by any specific CSVD feature or by CSVD scores (all Pinteraction >0.05). In 94 MIS patients with EOT ICH volume ≤15 mL, significant reduction in odds of poor outcome was found with cerebral amyloid angiopathy score <2 (OR, 0.14 (0.05–0.42); Pinteraction=0.006), absence of lacunes (OR, 0.37 (0.18–0.80); Pinteraction=0.02) and absence of severe white matter hyperintensities (WMHs) (OR, 0.22 (0.08–0.58); Pinteraction=0.03).ConclusionsFollowing successful haematoma reduction by MIS, we found significantly lower odds of poor functional outcome with lower total burden of CSVD in addition to absence of lacunes and severe WMHs. CSVD features may have utility for prognostication and patient selection in clinical trials of MIS.