Abstract
The Intravenous Magnesium Efficacy in Acute Stroke (IMAGES) trial is a multicentre,randomised, placebo-controlled trial of magnesium sulphate (MgSO4) funded by the UK Medical Research Council. When complete, it will be the largest single neuroprotective study undertaken to date. Conscious patients presenting within 12 h of acute stroke with limb weakness are eligible. The primary outcome measure is combined death and disability as measured using the Barthel Index at 90-day follow up. By randomizing 2700 patients, the study will have 84% power to detect a 5.5% absolute reduction in the primary end-point. By April 2000, 86 centres were participating, with representation in Canada, USA, Europe, South America, Singapore and Australia. So far, 1206 patients have been randomised, of whom 37% were treated within 6 h. Overall 3-month mortality was 20% and the primary outcome event rate was 43%. The study is ongoing and centres worldwide are encouraged to participate.
Highlights
Acute ischaemic stroke results in neurochemical and metabolic derangements that contribute to cell death in the ischaemic ‘penumbra’ surrounding an infarct core
Parenteral magnesium prevents the death of ischaemic neurones in standard experimental stroke models [1,2] and ADL = activities of daily living; CT = computed tomography; ICC = IMAGES Co-ordinating Centre; IMAGES = Intravenous Magnesium Efficacy in
Stroke severity at time of onset was classified for 1196 patients by the Oxfordshire Community Stroke Project (OCSP) categories total anterior circulation events (TACS), partial anterior circulation events (PACS), lacunar events (LACS), posterior circulation events (POCS) and unclassifiable
Summary
Acute ischaemic stroke results in neurochemical and metabolic derangements that contribute to cell death in the ischaemic ‘penumbra’ surrounding an infarct core. The potential viability of penumbral tissue has been affirmed by the consistent benefit of neuroprotective treatments targeted at a wide variety of metabolic derangements in the penumbra in animal models, which lead to biochemical, histological, radiological and functional recovery. An effective neuroprotective treatment for acute stroke in humans remains elusive. Relevant features may be as follows: increased cerebral blood flow after middle cerebral arterial occlusion [5]; antivasoconstrictor actions [6]; antagonism of calcium entry into cells via noncompetitive blockade of the N-methyl-D-aspartate receptor [7,8]; calcium antagonism at multiple voltagegated channels [9]; and enhanced recovery of vital magnesium-dependent cell functions, such as adenosine triphosphate levels and protein synthesis
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