Neurosurgical evacuation of intracranial hemorrhage after thrombolytic therapy for acute myocardial infarction: Experience from the GUSTO-I Trial☆,☆☆,★,★★,♢
Section snippets
Study population
The study population was the 41,021 patients enrolled in the GUSTO-I trial.3 In brief, patients with acute myocardial infarction within 6 hours of symptom onset were randomly assigned to 1 of 4 thrombolytic strategies: streptokinase 1.5 million U intravenously over a 60-minute period and subcutaneous heparin 12,500 U twice daily; streptokinase 1.5 million U intravenously over a 6-minute period and intravenous heparin, 5000-U bolus followed by 1000 U per hour; tPA in an accelerated regimen
Results
In the GUSTO-I trial, 268 cases of intracranial hemorrhage were observed. All patients with intracranial hemorrhage had computed axial tomography or magnetic resonance imaging scans, computed axial tomography, or magnetic resonance imaging reports and/or autopsy data to document intracranial hemorrhage. Adequate computed axial tomography or magnetic resonance imaging scans were available for analysis in 244 (91%) patients. Of the 268 cases, 228 (85.1%) were intraparenchymal hemorrhages, 12
Discussion
Neurosurgical evacuation is considered for selected patients with acute intracranial hemorrhage, particularly for those in whom there is substantial mass effect and progressive neurologic deficit. Standard procedures include craniotomy, craniectomy, or a closed drainage procedure by burr hole or twist drill.14 In the GUSTO-I trial, the 46 patients with intracranial hemorrhage who were treated with neurosurgical evacuation had significantly higher 30-day survival and a trend toward better
Acknowledgements
We thank John Daniel for his editorial support and help with manuscript preparation.
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Cited by (47)
Medical Therapy of Intracerebral and Intraventricular Hemorrhage
2021, Stroke: Pathophysiology, Diagnosis, and ManagementMedical Therapy of Intracerebral and Intraventricular Hemorrhage
2016, Stroke: Pathophysiology, Diagnosis, and ManagementRates and outcomes of neurosurgical treatment for postthrombolytic intracerebral hemorrhage in patients with acute ischemic stroke
2014, World NeurosurgeryCitation Excerpt :The reported incidence of postthrombolytic ICH in patients with acute myocardial infarction ranges from 0.3%–0.8% with high rates of mortality and major disability (1, 2, 4, 17, 30). In the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial, 268 (0.65%) patients experienced life-threatening postthrombolytic ICH after thrombolytic therapy for acute myocardial infarction (22). Approximately 82% of the ICHs were intraparenchymal, and the rest were a combination of subdural hemorrhages and ICHs.
Neurologic Manifestations of Acquired Cardiac Disease, Arrhythmias, and Interventional Cardiology
2014, Aminoff's Neurology and General Medicine: Fifth EditionNeurointerventional therapies for stroke in atrial fibrillation: Illustrated cases
2014, Cardiac Electrophysiology ClinicsCitation Excerpt :This patient underwent a craniotomy to decompress the brain, in order to avert herniation. Neurosurgical evacuation for intracerebral bleeding caused by thrombolysis is controversial, although, in the GUSTO-I trial of thrombolysis for myocardial infarction, the 30-day survival was significantly higher with evacuation than without (65% vs 35%) and there was a trend toward better functional outcomes (20% vs 12% respectively).38 A 77-year-old man with history of ischemic cardiomyopathy, hypertension, status post implantable cardioverter defibrillator (ICD) placement, congestive heart failure, and paroxysmal AF (CHADS2, 3; CHA2DS2VASc, 4) presented to the emergency department with a syncopal episode at home.
Neurologic complications of myocardial infarction
2014, Handbook of Clinical NeurologyCitation Excerpt :Neurosurgical intervention may be needed to alleviate raised intracranial pressure or to evacuate hematomas (Sloan et al., 1995). Mahaffey et al. examined neurosurgical evacuation of intracranial hemorrhage after thrombolytic therapy for acute myocardial infarction from the Global Utilization of Streptokinase and Tissue-Plasminogen Activator (tPA) for Occluded Coronary Arteries (GUSTO-1) trial where they randomly assigned 41 021 patients with acute myocardial infarction to one of four thrombolytic strategies in 1081 hospitals in 15 countries and found that rapid neurosurgical intervention may be beneficial in selected cases (Mahaffey et al., 1999a), but evidence from randomized clinical trials is lacking. Primary angioplasty should decrease hemorrhagic stroke rates, and the introduction of newer thrombolytic agents, weight-adjusted administration of heparin, low-molecular weight heparins, and a new generation of antiplatelet drugs may also affect stroke rates as well as determinants of intracranial hemorrhage in patients with acute myocardial infarction (Huynh et al., 2004).
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From the aDuke Clinical Research Institute, Duke University Medical Center, Durham.bDepartment of Neuroscience, Harbin Clinic, Rome.cUniversity of Massachusetts Medical Center, Worcester.dHenry Ford Foundation, Detroit.eGreen Lane Hospital, Auckland.fThoraxcenter, Erasmus University, Rotterdam.gSourasky Medical Center, Tel Aviv; and hthe Cleveland Clinic Foundation, Cleveland.
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Supported by Bayer (New York, NY), CIBA-Corning (Medfield, Mass), Genentech (South San Francisco, Calif), ICI Pharmaceuticals (Wilmington, Del), and Sanofi Pharmaceuticals (Paris, France).
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Guest Editor for this manuscript was Frank V. Aguirre, MD, Prairie Cardiovascular Consultants, Springfield, Ill.
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Reprint requests: Kenneth W. Mahaffey, MD, PO Box 17969, Duke Clinical Research Institute, Durham, NC 27715.
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