Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure
Authors: Awad Issam A , Polster Sean P , Carrión-Penagos Julián , Thompson Richard E , Cao Ying , Stadnik Agnieszka , Money Patricia Lynn , Fam Maged D , Koskimäki Janne , Girard Romuald , Lane Karen , McBee Nichol , Ziai Wendy , Hao Yi , Dodd Robert , Carlson Andrew P , Camarata Paul J , Caron Jean-Louis , Harrigan Mark R , Gregson Barbara A , Mendelow A David , Zuccarello Mario , Hanley Daniel F ,   MISTIE III Trial Investigators, Abdul-Rahim Azmil , Abou-Hamden Amal , Abraham Michael , Ahmed Azam , Alba Carlos Alarcon , Aldrich E Francois , Ali Hasan , Altschul David , Amin-Hanjani Sepideh , Anderson Craig S , Anderson Doug , Ansari Safdar , Antezana David , Ardelt Agnieszka , Arikan Fuat , Avadhani Radhika , Baguena Marcelino , Baker Alexandra , Barrer Steven J , Barzo Pal , Becker Kyra J , Bergman Thomas , Betz Joshua F , Bistran-Hall Amanda J , Boström Azize , Braun Jamie , Brindley Peter , Broaddus William C , Brown Robert , Buki Andras , Bulters Diederik , Cao Bing , Carhuapoma J Ricardo , Chalela Julio , Chang Tiffany , Chicoine Michael R , Chorro Indalecio Moran , Chowdhry Shakeel , Cobb Cully , Corral Luisa , Csiba Laszlo , Davies Jason , Dawson Jesse , Díaz Alberto Torres , Dierdeyn Colin P , Diringer Michael , Dlugash Rachel , Ecker Robert , Economas Tracey , Enriquez Pedro , Ezer Erzsebet , Fan Yuhua , Feng Hua , Franz Douglas , Freeman W David , Fusco Matthew , Galicich Walter , Gandhi Dheeraj , Gelea Mary Leigh , Goldstein Joshua , Gonzalez Alejandro Carrasco , Grabarits Christina , Greenberg Steven , Gregson Barbara , Gress Daryl , Gu Eugene , Gupta Gaurav , Hall Christiana , Harnof Sagi , Hernandez Fernando Muñoz , Hoesch Robert , Hoh Brian L , Houser Jennifer , Hu Rong , Huang Judy , Huang Yi , Hussain Mohammed Akbar , Insinga Salvatore , Jadhav Ashutosh , Jaffe Jennifer , Jahromi Babak S , Jallo Jack , James Michael , James Robert F , Janis Scott , Jankowitz Brian , Jeon Esther , Jichici Draga , Jonczak Karin , Jonker Ben , Karlen Nicki , Kase Carlos S , Keric Naureen , Kerz Thomas , Kitagawa Ryan , Knopman Jared , Koenig Carolyn , Krishnamurthy Satish , Kumar Avinash , Kureshi Inam , Laidlaw John , Lakhanpal Arun , Latorre Julius Gene , LeDoux David , Lees Kennedy R , Leifer Dana , Leiphart James , Lenington Sarah , Li Yunke , Lopez George , Lovick Darren , Lumenta Christianto , Luo Jinbiao , Maas Matthew B , MacDonald Joel , MacKenzie Larami , Madan Vikram , Majkowski Ryan , Major Otto , Malhorta Rishi , Malkoff Marc , Mangat Halinder , Maswadeh Ahmed , Matouk Charles , Mayo Steven W , McArthur Kate , McCaul Scott , Medow Joshua , Mezey Geza , Mighty Janet , Miller David , Mitchell Patrick , Mohan Krishna K , Mould W Andrew , Muir Keith , Muñoz Lorenzo , Nakaji Peter , Nee Alex , Nekoovaght-Tak Saman , Nyquist Paul , O'Kane Roddy , Okasha Mohamed , O'Kelly Cian , Ostapkovich Noeleen , Pandey Aditya , Parry-Jones Adrian , Patel Hiren , Perla Krissia Rivera , Pollack Ania , Pouratian Nader , Quinn Terry , Rajajee Ventatakrishna , Reddy Kesava , Rehman Mohammed , Reimer Ronald , Rincon Fred , Rosenblum Michael , Rybinnik Igor , Sanchez Baltasar , Sansing Lauren , Sarabia Rosario , Schneck Michael , Schuerer Ludwig , Schul David , Schweitzer Jeffrey , Seder David B , Seyfried Donald , Sheth Kevin , Spiotta Alejandro , Stechison Michael , Sugar Elizabeth A , Szabo Katalin , Tamayo Gonzalo , Tanczos Krisztian , Taussky Philipp , Teitelbaum Jeanne S , Terry John , Testai Fernando , Thomas Kathrine , Thompson Carol B , Thompson Gregory , Torner James C , Tran Huy , Tucker Kristi , Ullman Natalie , Ungar Lior , Unterberg Andreas , Varelas Panos , Vargas Nataly Montano , Vatter Hartmut , Venkatasubramanian Chitra , Vermillion Krista , Vespa Paul , Vollmer Dennis , Wang Weimin , Wang Yan , Wang Ying , Wen Jiajun , Whitworth Louis Tony , Willis Byron , Wilson Alastair , Wolfe Stacey , Wrencher Myriha , Wright Shawn E , Xu Yongge , Yanase Lisa , Yenokyan Gayane , Yi Xuxia , Yu Zhiyuan , Zomorodi Ali 
Published: February 2019

Abstract

BACKGROUND
Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr).

OBJECTIVE
To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes.

METHODS
Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial.

RESULTS
Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation.

CONCLUSION
This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.