Assessing the benefits of hemicraniectomy: what is a favourable outcome? – Authors' reply

T reatment options for acute ischemic stroke are limited to thrombolysis, aspirin, hemicraniectomy and stroke unit care, [1][2][3][4] and mechanical thrombectomy. [5][6][7] Although there are no definitive treatments for acute intracerebral hemorrhage, lowering blood pressure (BP) might be beneficial. 8 As a result, new interventions are still needed and, ideally, ones that are simple to administer and relevant irrespective of stroke type so that they can be given prehospital or immediately on admission to hospital before neuroimaging.Nitric oxide (NO) donors are a candidate treatment for acute stroke. [9][10][11] In preclinical studies, NO donors reduced lesion size and increased cerebral blood flow, but only if given early. 12 In multiple pilot randomized controlled trials, NO donors (specifically intravenous sodium nitroprusside and transdermal glyceryl trinitrate [GTN]) reduced BP, pulse pressure, variability, and peak systolic BP; maintained cerebral blood flow (in spite of BP reduction); and improved arterial compliance. [13][14][15][16][17] Although sodium nitroprusside attenuated platelet function, GTN had no effect on platelets, 13,14 suggesting that it could be given to patients whether they had ischemic or hemorrhagic stroke. In a small trial of GTN administered by paramedics before hospital admission (with median time toBackground and Purpose-Nitric oxide donors are candidate treatments for acute stroke, potentially through hemodynamic, reperfusion, and neuroprotectant effects, especially if given early. Although the large Efficacy of Nitric Oxide in Stroke (ENOS) trial of transdermal glyceryl trinitrate (GTN) was neutral, a prespecified subgroup suggested that GTN improved functional outcome if administered early after stroke onset. Methods-Prospective analysis of subgroup of patients randomized into the ENOS trial within 6 hours of stroke onset.Safety and efficacy of GTN versus no GTN were assessed using data on early and late outcomes. Results-Two hundred seventy-three patients were randomized within 6 hours of ictus: mean (SD) age, 69.9 (12.7) years; men, 154 (56.4%); ischemic stroke, 208 (76.2%); Scandinavian Stroke Scale, 32.1 (11.9); and total anterior circulation syndrome, 86 (31.5%). When compared with no GTN, the first dose of GTN lowered blood pressure by 9.4/3.3 mm Hg (P<0.01, P=0.064) and shifted the modified Rankin Scale to a better outcome by day 90, adjusted common odds ratio, 0.51 (95% confidence interval, 0.32-0.80). Significant beneficial effects were also seen with GTN for disability (Barthel Index), quality of life (EuroQol-Visual Analogue Scale), cognition (telephone Mini-Mental State Examination), and mood (Zung Depression Scale admission of 55 minutes), GTN seemed to improve functional outcome, assessed as the modified Rankin Scale (mRS). 17When assessed in a large international trial involving patients with stroke within 48 hours, GTN was safe to administer but did not alter mRS, the primary outcome. 18The potential benefit of GTN when administered early 17 suggested that the...

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confidence: 99%

Effect of Hyperacute Administration (Within 6 Hours) of Transdermal Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome After Stroke

Woodhouse

Scutt

Krishnan

et al. 2015

Stroke

100

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“…12 In the pooled analysis of the 3 European stroke trials published in 2007, it was only possible to demonstrate a significant improvement in favorable outcome by recategorizing favorable as a mRS score of ≤4. 13 This would therefore include patients who were unable to walk unaided and unable to attend to their own bodily needs without assistance, but it could be argued that, given that these are relatively young people and the alternative would be not to survive at all, a patient may reasonably want to be given the chance to risk survival with an mRS score of 4 (immobile and dependent) in the hope that they will either achieve an mRS score of 3 or learn to accept a level of disability that they might previously have deemed unacceptable.…”

Section: Long-term Outcomementioning

confidence: 99%

Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

Honeybul

Gillett

2015

Stroke

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“…Dedicated personnel in critical care medicine and stroke neurology are on call 24/7, advanced neuroimaging and interpretation is readily available, and specialized neuroscience nursing is equipped to provide individualized care. In addition, a pooled analysis of 3 prospective trials of decompressive craniectomy for large hemispheric infarction demonstrated a clear benefit, 4 and in appropriate cases, surgery may be appropriate. The optimization and monitoring of patients before surgery requires the ready availability of intensivists and neurosurgeons around the clock.…”

Section: Sheth Early Transfer Of Patients With Strokementioning

confidence: 99%

Early Transfer of Patients With Stroke to Comprehensive Centers Is Necessary

Sheth

2014

Stroke

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Assessing the benefits of hemicraniectomy: what is a favourable outcome? – Authors' reply

Cited by 27 publications

References 2 publications

Effect of Hyperacute Administration (Within 6 Hours) of Transdermal Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome After Stroke

Effect of Hyperacute Administration (Within 6 Hours) of Transdermal Glyceryl Trinitrate, a Nitric Oxide Donor, on Outcome After Stroke

Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

Early Transfer of Patients With Stroke to Comprehensive Centers Is Necessary

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