Stroke; a journal of cerebral circulation
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Randomized Controlled Trial Multicenter Study
Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial.
Decompressive surgery (hemicraniectomy) for life-threatening massive cerebral infarction represents a controversial issue in neurocritical care medicine. We report here the 30-day mortality and 6- and 12-month functional outcomes from the DESTINY trial. ⋯ DESTINY showed that hemicraniectomy reduces mortality in large hemispheric stroke. With 32 patients included, the primary end point failed to demonstrate statistical superiority of hemicraniectomy, and the projected sample size was calculated to 188 patients. Despite this failure to meet the primary end point, the steering committee decided to terminate the trial in light of the results of the joint analysis of the 3 European hemicraniectomy trials.
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Randomized Controlled Trial Multicenter Study
Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial).
There is no effective medical treatment of malignant middle cerebral artery (MCA) infarction. The purpose of this clinical trial was to assess the efficacy of early decompressive craniectomy in patients with malignant MCA infarction. ⋯ In this trial, early decompressive craniectomy increased by more than half the number of patients with moderate disability and very significantly reduced (by more than half) the mortality rate compared with that after medical therapy.
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Race/ethnicity is associated with overall incidence of intracranial hemorrhage (ICH), but its impact in patients with brain arteriovenous malformation is unknown. We evaluated whether race/ethnicity was a risk factor for ICH in the natural course in a large, multiethnic cohort of patients with brain arteriovenous malformation followed longitudinally. ⋯ This study reports the first description of race/ethnic differences in brain arteriovenous malformation, with Hispanics at an increased risk of subsequent ICH compared with whites.
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Randomized Controlled Trial
Therapeutic benefit of low-dose clopidogrel in patients undergoing carotid surgery is linked to variability in the platelet adenosine diphosphate response and patients' weight.
We have previously shown that a single 75-mg tablet of clopidogrel, taken before carotid endarterectomy, significantly reduces postoperative embolization, a marker of thromboembolic stroke. This study explores the antiplatelet effect of this submaximal dose. ⋯ These results explain how a single 75-mg dose of clopidogrel produces a significant clinical impact on embolization.
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Delayed cerebral infarction (DCI) is an important cause of poor outcome after subarachnoid hemorrhage. Cerebral perfusion is a predictor for DCI. Because acute hydrocephalus may impair cerebral perfusion, we evaluated the predictive value of the extent of acute hydrocephalus on the development of DCI. ⋯ Acute hydrocephalus is not a risk factor for occurrence of DCI, even when the extent of hydrocephalus is taken into account. However, we cannot exclude the possibility that extensive hydrocephalus leading to coma does increase the risk for DCI if no therapeutic intervention were done.