Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis

2017 ◽  
Vol 10 (4) ◽  
pp. 380-387 ◽  
Author(s):  
Anand Venkatraman ◽  
Ayaz M Khawaja ◽  
Sahil Gupta ◽  
Shalaka Hardas ◽  
John P Deveikis ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Patient Selection ◽  
Balloon Angioplasty ◽  
Medical Management ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Neurological Improvement ◽  
Good Outcome ◽  
Neurological Response

ObjectiveThe efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs.MethodsWe searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model.ResultsInclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management).ConclusionIAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.

Abstract TMP105: Endovascular Treatment of Severe and Refractory Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Improves Outcome: A Systematic Review and Meta-analysis of Different Treatment Options Evaluated Since 2006 for Cerebral Vasospasm

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Gregoire Boulouis ◽  
Marc-Antoine Labeyrie ◽  
Jean Raymond ◽  
Christine Rodriguez-Regent ◽  
Anne-Claire Lukaszewicz ◽  
...  
Keyword(s):  
Systematic Review ◽  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Endovascular Treatment ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Route Of Administration ◽  
Unfavorable Outcome ◽  
Q Value

Introduction: To report clinical outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS) targeted treatments in a systematic review and meta-analysis and compare the efficacy of endovascular and non-endovascular treatments in severe / refractory vasospasm patients. Methods: The literature was searched using PubMed, EMBASE, and The Cochrane Library database. Eligibility criteria were (1) Rated clinical outcome; (2) at least 10 patients; (3) aSAH; (4) study published in English or French (January 2006 - October 2014); and (5) methodological quality score > 10, according to STROBE criteria. Endpoint included unfavorable outcome rate, defined as mRS 3-6, GOS 1-3 or GOSE 1-4 at latest follow-up. Analyses included stratification per route of administration (oral, i.v., intra-arterial or cisternoventricular) and per study inclusion criteria (severe, CVS, refractory CVS or high risk for CVS). Univariate and multivariate subgroup analyses were performed to identify interventions associated with a better outcome. Results: Sixty-two studies, including 26 randomized controlled trials, were included (8976 patients). Overall 2490 patients had unfavorable outcome including death (random-effect weighted average: 33.7%, 99%CI, 28.1-39.7%; Q-value: 806.0, I 2 =92.7%). Clinical outcome was significantly better in severe or refractory patients for whom, on top of best medical treatment, endovascular intervention was performed (RR=0.76, IC95% [0.66-0.89], p <0.00001) whereas other route of administration didn’t show significant differences. RR of unfavorable outcome was significantly lower, vs control groups, in patients treated with Cilostazol (RR=0.46 (IC99% [0.25-0.85], P = 0.001, Q value 1.5, I 2 = 0). Conclusion: In case of CVS following aSAH, endovascular treatment in severe / refractory vasospasm patients. including intra-arterial injection of pharmacological agents or balloon angioplasty, improves outcome as compared to other route of administration.

scholarly journals Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage

2017 ◽  
Vol 23 (4) ◽  
pp. 372-377 ◽  
Author(s):  
Nauman S Chaudhry ◽  
Jennifer L Orning ◽  
Sophia F Shakur ◽  
Sepideh Amin-Hanjani ◽  
Victor A Aletich ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Artery ◽  
Balloon Angioplasty ◽  
Anterior Cerebral Artery ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Infusion Therapy ◽  
Safety And Efficacy ◽  
Neurological Improvement ◽  
Symptomatic Vasospasm ◽  
Radiographic Measurements

Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25–50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.

scholarly journals Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis

2011 ◽  
Vol 31 (6) ◽  
pp. 1443-1451 ◽  
Author(s):  
Nima Etminan ◽  
Mervyn DI Vergouwen ◽  
Don Ilodigwe ◽  
R Loch Macdonald
Keyword(s):  
Systematic Review ◽  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Clinical Outcome ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Delayed Cerebral Ischemia ◽  
Double Blind ◽  
Poor Outcome ◽  
Methodological Problems

As it is often assumed that delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is caused by vasospasm, clinical trials often focus on prevention of vasospasm with the aim to improve clinical outcome. However, the role of vasospasm in the pathogenesis of DCI and clinical outcome is possibly smaller than previously assumed. We performed a systematic review and meta-analysis on all randomized, double-blind, placebo-controlled trials that studied the effect of pharmaceutical preventive strategies on vasospasm, DCI, and clinical outcome in SAH patients to further investigate the relationship between vasospasm and clinical outcome. Effect sizes were expressed in pooled risk ratio (RR) estimates with corresponding 95% confidence intervals (CI). A total of 14 studies randomizing 4,235 patients were included. Despite a reduction of vasospasm (RR 0.80 (95% CI 0.70 to 0.92)), no statistically significant effect on poor outcome was observed (RR 0.93 (95% CI 0.85 to 1.03)). The variety of DCI definitions did not justify pooling the DCI data. We conclude that pharmaceutical treatments have significantly decreased the incidence of vasospasm, but not of poor clinical outcome. This dissociation between vasospasm and clinical outcome could result from methodological problems, sample size, insensitivity of clinical outcome measures, or from mechanisms other than vasospasm that also contribute to poor outcome.

scholarly journals Effectiveness comparisons of drug therapies for postoperative aneurysmal subarachnoid hemorrhage patients: network meta‑analysis and systematic review

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Wanli Yu ◽  
Yizhou Huang ◽  
Xiaolin Zhang ◽  
Huirong Luo ◽  
Weifu Chen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Glasgow Outcome Scale ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Statistical Significance ◽  
Cochrane Library ◽  
Curative Effect ◽  
Clinical Prognosis ◽  
Drug Interventions

Abstract Objective To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis. Methods Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies. Results From the 493 of initial citation screening, forty-four RCTs (n = 10,626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR = 3.35,95%CI = 1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA = 87.29%, 95%CrI 0.07–0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR = 1.61, 95%CI 1.01,2.57) and cilostazol (OR = 3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. Conclusions Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively.

Cardiac Arrest in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Single-Center Experience

2019 ◽  
Vol 80 (06) ◽  
pp. 409-412
Author(s):  
Sami Ridwan ◽  
Rudolf Kristof
Keyword(s):  
Cardiac Arrest ◽  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Statistical Significance ◽  
Case Fatality ◽  
Poor Grade ◽  
Good Outcome ◽  
Grade 5 ◽  
Clinical Records

Abstract Background Poor-grade aneurysmal subarachnoid hemorrhage (SAH), in particular Hunt and Hess (H&H) grade 5 SAH, still has a high case-fatality rate. Recent studies regarding the clinical outcome of such patients and the influence of comorbidities, especially cardiac arrest (CA) requiring additional cardiopulmonary resuscitation (CPR), on the outcome of these patients are scant. Our primary objective was to assess the outcome of SAH H&H grade 5 patients and the influence of additional CA and requirement for CPR. Methods All patients with spontaneous aneurysmal SAH H&H grade 5 admitted to our hospital from 2001 to 2010 were enrolled in the study. Data were extracted from the hospital's clinical records and electronic database. The patients' clinical outcome at time of discharge was represented by the Glasgow Outcome Score and modified Rankin Scale (mRS). The influence of CA and additional CPR on patient outcome was analyzed. Results Of 80 SAH H&H grade 5 patients (median age 55 years), 21 patients (median age 50 years) experienced CA and received additional CPR. Mortality in SAH H&H grade 5 patients was 85% with CA and 68% without CA (p = 0.158). Overall, 22 of 59 patients with no CA survived, 4 with a good clinical outcome (mRS 0–3). Of the 21 with CA, only 3 survived, none with a good outcome (mRS 4–5). Due to the small subgroup surviving additional CA, a statistical difference could not be found between the groups. Aneurysm occlusion (p < 0.001) and aneurysm of the posterior circulation (p = 0.010) resulted in a more favorable clinical outcome. Conclusions Patients with SAH H&H grade 5 do survive and in 5% of cases even with a good outcome. Surviving an additional CA resulted in a less favorable outcome without statistical significance. Thus SAH H&H grade 5 patients with or without CA and additional CPR should not be excluded from appropriate neurosurgical treatment.

scholarly journals Effectiveness Comparisons of Drug Therapies for Postoperative Aneurysmal Subarachnoid Hemorrhage Patients: Network Meta‑analysis and systematic review

2021 ◽  
Author(s):  
Wanli Yu ◽  
Yizhou Huang ◽  
Xiaolin Zhang ◽  
Huirong Luo ◽  
Weifu Chen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Glasgow Outcome Scale ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Statistical Significance ◽  
Cochrane Library ◽  
Curative Effect ◽  
Clinical Prognosis ◽  
Drug Interventions

Abstract Objective: To compare the effectiveness of various drug interventions in improving the clinical outcome of postoperative patients after aneurysmal subarachnoid hemorrhage (aSAH) and assist in determining the drugs of definite curative effect in improving clinical prognosis.Methods: Eligible Randomized Controlled Trials (RCTs) were searched in databases of PubMed, EMBASE, and Cochrane Library (inception to Sep 2020). Glasgow Outcome Scale (GOS) score, Extended Glasgow Outcome Scale (GOSE) score or modified Rankin Scale (mRS) score was used as the main outcome measurements to evaluate the efficacy of various drugs in improving the clinical outcomes of postoperative patients with aSAH. The network meta-analysis (NMA) was conducted based on a random-effects model, dichotomous variables were determined by using odds ratio (OR) with 95% confidence interval (CI), and a surface under the cumulative ranking curve (SUCRA) was generated to estimate the ranking probability of comparative effectiveness among different drug therapies.Results: From the 493 of initial citation screening, forty-four RCTs (n=10626 participants) were eventually included in our analysis. Our NMA results showed that cilostazol (OR=3.35,95%CI=1.50,7.51) was the best intervention to improve the clinical outcome of patients (SUCRA=87.29%, 95%CrI 0.07-0.46). Compared with the placebo group, only two drug interventions [nimodipine (OR=1.61, 95%CI 1.01,2.57) and cilostazol (OR=3.35, 95%CI 1.50, 7.51)] achieved significant statistical significance in improving the clinical outcome of patients. Conclusions: Both nimodipine and cilostazol have exact curative effect to improve the outcome of postoperative patients with aSAH, and cilostazol may be the best drug to improve the outcome of patients after aSAH operation. Our study provides implications for future studies that, the combination of two or more drugs with relative safety and potential benefits (e.g., nimodipine and cilostazol) may improve the clinical outcome of patients more effectively.

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