Does Intracisternal Thrombolysis Prevent Vasospasm after Aneurysmal Subarachnoid Hemorrhage? A Meta-analysis

Neurosurgery ◽  
2004 ◽  
Vol 54 (2) ◽  
pp. 326-335 ◽  
Author(s):  
Sepideh Amin-Hanjani ◽  
Christopher S. Ogilvy ◽  
Fred G. Barker
Keyword(s):  
Subarachnoid Hemorrhage ◽  
High Risk ◽  
Confidence Interval ◽  
Glasgow Outcome Scale ◽  
Treatment Effects ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Neurological Deficits ◽  
Controlled Trials ◽  
Scale Scores

Abstract OBJECTIVE Despite existing strategies for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage, vasospasm remains a persistent contributor to death and disability. The intracisternal application of thrombolytic agents to dissolve subarachnoid clot has been advocated. The goal of this analysis was to assess the currently available evidence regarding the effectiveness of this treatment. METHODS We conducted a systematic review of the published literature; all controlled trials were included. The outcomes of interest were delayed ischemic neurological deficits, poor Glasgow Outcome Scale scores, and death. A formal meta-analysis was performed with a random-effects model. RESULTS The search revealed nine trials or trial subgroups (only one of which was randomized), with a total enrollment of 652 patients. Pooled results demonstrated beneficial effects of treatment, with absolute risk reductions of 14.4% (95% confidence interval, 6.5–22.5%; P < 0.001) for delayed ischemic neurological deficits, 9.5% (95% confidence interval, 4.2–14.8%; P < 0.01) for poor Glasgow Outcome Scale scores, and 4.5% (95% confidence interval, 1.5–7.5%; P < 0.05) for death. Regression analysis revealed that treatment effects did not significantly differ among the studies on the basis of the type of thrombolytic agent used (tissue plasminogen activator versus urokinase) or the method of administration (intraoperative versus postoperative) (P > 0.10). Studies that enrolled only patients at high risk for vasospasm seemed to demonstrate greater treatment effects. CONCLUSION The meta-analysis suggests a clinically relevant and statistically significant beneficial effect of intracisternal thrombolysis. However, the results of the analysis are limited by the predominance of nonrandomized studies. Further randomized, blinded, placebo-controlled trials of high-risk patients would be justified.

Dissociation of vasospasm-related morbidity and outcomes in patients with aneurysmal subarachnoid hemorrhage treated with clazosentan: a meta-analysis of randomized controlled trials

2013 ◽  
Vol 119 (1) ◽  
pp. 180-189 ◽  
Author(s):  
Jian Shen ◽  
Jian-Wei Pan ◽  
Zuo-Xu Fan ◽  
Xiao-Xing Xiong ◽  
Ren-Ya Zhan
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Randomized Controlled Trials ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Statistical Significance ◽  
Pulmonary Complications ◽  
Neurological Deficits ◽  
Controlled Trials ◽  
Eligibility Criteria ◽  
Randomized Controlled

Object Clazosentan therapy after aneurysmal subarachnoid hemorrhage (SAH) has been found to be effective in reducing the incidence of vasospasm in randomized controlled trials. However, while vasospasm-related morbidity, including delayed ischemic neurological deficits (DINDs) and delayed cerebral infarctions, was consistently decreased, statistical significance was not demonstrated and outcomes were not affected by clazosentan treatment. The objective of this meta-analysis was to determine whether clazosentan treatment after aneurysmal SAH significantly reduced the incidence of DINDs and delayed cerebral infarctions and improved outcomes. Methods All randomized controlled trials investigating the effect of clazosentan were retrieved via searches with sensitive and specific terms. Six variables were abstracted after the assessment of the methodological quality of the trials. Analyses were performed following the method guidelines of the Cochrane Back Review Group. Results Four randomized, placebo-controlled trials met eligibility criteria, enrolling a total of 2181 patients. The meta-analysis demonstrated a significant decrease in the incidence of DINDs (relative risk [RR] 0.76 [95% CI 0.62–0.92]) and delayed cerebral infarction (RR 0.79 [95% CI 0.63–1.00]) in patients treated with clazosentan after aneurysmal SAH. However, this treatment regimen was not shown to outcomes including functional outcomes measured by Glasgow Outcome Scale-Extended (RR 1.12 [95% CI 0.96–1.30]) or mortality (RR 1.02 [95%CI 0.70–1.49]). Adverse events, including pulmonary complications, anemia, and hypotension, were all significantly increased in patients who received clazosentan therapy. Conclusions The results of the present meta-analysis show that treatment with clazosentan after aneurysmal SAH significantly reduced the incidence of the vasospasm-related DINDs and delayed cerebral infarctions, but did not improve poor neurological outcomes in patients with aneurysmal SAH. Further study is required to elucidate the dissociation between vasospasm-related morbidity and outcomes.

Correlation Among Systemic Inflammatory Parameter, Occurrence of Delayed Neurological Deficits, and Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2012 ◽  
Vol 72 (3) ◽  
pp. 367-375 ◽  
Author(s):  
Carl Muroi ◽  
Michael Hugelshofer ◽  
Martin Seule ◽  
Ilhan Tastan ◽  
Masayuki Fujioka ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Confidence Interval ◽  
Early Phase ◽  
Odds Ratio ◽  
Time Course ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Unfavorable Outcome ◽  
Neurological Deficits ◽  
Inflammatory Parameters ◽  
Leukocyte Counts

Abstract BACKGROUND: The role and impact of systemic inflammatory response after aneurysmal subarachnoid hemorrhage remain to be elucidated. OBJECTIVE: To assess the time course and correlation of systemic inflammatory parameters with outcome and the occurrence of delayed ischemic neurological deficits (DINDs) after subarachnoid hemorrhage. METHODS: Besides the baseline characteristics, daily interleukin-6 (IL-6), procalcitonin, C-reactive protein levels, and leukocyte counts were prospectively measured until day 14 after subarachnoid hemorrhage. Occurrence of infectious complications and application of therapeutic hypothermia were assessed as confounding factors. The primary end point was outcome after 3 months, assessed by Glasgow Outcome Scale; the secondary end point was the occurrence of DINDs. RESULTS: During a 3-year period, a total of 138 patients were included. All inflammatory parameters measured were higher in patients with unfavorable outcome (Glasgow Outcome Scale score, 1-3). After adjustment for confounding factors, elevated IL-6 and leukocyte counts remained significant risk factors for unfavorable outcome. The odds ratio for log IL-6 was 4.07 (95% confidence interval, 1.18 to 14.03; P = .03) and for leukocyte counts was 1.24 (95% confidence interval, 1.06-1.46, P = .008). The analysis of the time course established that IL-6 was the only significantly elevated parameter in the early phase in patients with unfavorable outcome. Higher IL-6 levels in the early phase (days 3-7) were associated with the occurrence of DINDs. The adjusted odds ratio for log IL-6 was 4.03 (95% confidence interval, 1.21-13.40; P = .02). CONCLUSION: Higher IL-6 levels are associated with worse clinical outcome and the occurrence of DINDs. Because IL-6 levels were significantly elevated in the early phase, they might be a useful parameter to monitor.

Effects of decompressive craniectomy on functional outcomes and death in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

2017 ◽  
Vol 127 (6) ◽  
pp. 1315-1325 ◽  
Author(s):  
Naif M. Alotaibi ◽  
Ghassan Awad Elkarim ◽  
Nardin Samuel ◽  
Oliver G. S. Ayling ◽  
Daipayan Guha ◽  
...  
Keyword(s):  
Systematic Review ◽  
Subarachnoid Hemorrhage ◽  
Decompressive Craniectomy ◽  
Glasgow Outcome Scale ◽  
Functional Outcomes ◽  
Event Rate ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Meta Analysis ◽  
Unfavorable Outcome ◽  
Poor Grade

OBJECTIVEPatients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) (World Federation of Neurosurgical Societies Grade IV or V) are often considered for decompressive craniectomy (DC) as a rescue therapy for refractory intracranial hypertension. The authors performed a systematic review and meta-analysis to assess the impact of DC on functional outcome and death in patients after poor-grade aSAH.METHODSA systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified through the Ovid Medline, Embase, Web of Science, and Cochrane Library databases from inception to October 2015. Only studies dedicated to patients with poor-grade aSAH were included. Primary outcomes were death and functional outcome assessed at any time period. Patients were grouped as having a favorable outcome (modified Rankin Scale [mRS] Scores 1–3, Glasgow Outcome Scale [GOS] Scores 4 and 5, extended Glasgow Outcome Scale [GOSE] Scores 5–8) or unfavorable outcome (mRS Scores 4–6, GOS Scores 1–3, GOSE Scores 1–4). Pooled estimates of event rates and odds ratios with 95% confidence intervals were calculated using the random-effects model.RESULTSFifteen studies encompassing 407 patients were included in the meta-analysis (all observational cohorts). The pooled event rate for poor outcome across all studies was 61.2% (95% CI 52%–69%) and for death was 27.8% (95% CI 21%–35%) at a median of 12 months after aSAH. Primary (or early) DC resulted in a lower overall event rate for unfavorable outcome than secondary (or delayed) DC (47.5% [95% CI 31%–64%] vs 74.4% [95% CI 43%–91%], respectively). Among studies with comparison groups, there was a trend toward a reduced mortality rate 1–3 months after discharge among patients who did not undergo DC (OR 0.58 [95% CI 0.27–1.25]; p = 0.168). However, this trend was not sustained at the 1-year follow-up (OR 1.09 [95% CI 0.55–2.13]; p = 0.79).CONCLUSIONSResults of this study summarize the best evidence available in the literature for DC in patients with poor-grade aSAH. DC is associated with high rates of unfavorable outcome and death. Because of the lack of robust control groups in a majority of the studies, the effect of DC on functional outcomes versus that of other interventions for refractory intracranial hypertension is still unknown. A randomized trial is needed.

scholarly journals Use of NSAIDs via the Rectal Route for the Prevention of Pancreatitis after ERCP in All-Risk Patients: An Updated Meta-Analysis

2018 ◽  
Vol 2018 ◽  
pp. 1-10 ◽  
Author(s):  
Lei-Min Yu ◽  
Ke-Jia Zhao ◽  
Bin Lu
Keyword(s):  
High Risk ◽  
Confidence Interval ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Rectal Administration ◽  
Controlled Trials ◽  
Randomized Controlled ◽  
Rectal Route ◽  
Risk Patients ◽  
Inflammatory Drugs

The aim of this study was to assess the efficacy of the rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing post-ERCP pancreatitis (PEP). We searched database for randomized controlled trials (RCTs) comparing periprocedural rectal administration of NSAIDs with placebo for the prevention of PEP. The rectal administration of NSAIDs significantly decreased the incidence of PEP in the whole patient population (odds ratio (OR): 0.44, 95% confidence interval (CI): 0.30–0.64, P<0.0001), high-risk patients (OR: 0.34, 95% CI: 0.19–0.58, P=0.0001), and all-risk patients (OR: 0.51, 95% CI: 0.31–0.84, P=0.008). The incidence of PEP was reduced by indomethacin (OR: 0.54, 95% CI: 0.36–0.82, P=0.004) and diclofenac (OR: 0.27, 95% CI: 0.15–0.46, P<0.00001). The administration of NSAIDs before (OR: 0.42, 95% CI: 0.25–0.73, P=0.002) or after (OR: 0.39, 95% CI: 0.27–0.56, P<0.00001) ERCP reduced PEP. The NSAIDs were associated with a reduction in mild PEP (OR: 0.55, 95% CI: 0.36–0.83, P=0.004) and moderate-to-severe PEP (OR: 0.47, 95% CI: 0.28–0.79, P=0.004). The rectal administration of NSAIDs reduced the incidence of PEP in high-risk and all-risk patients.

Effects of Timing of Coil Embolization after Aneurysmal Subarachnoid Hemorrhage on Procedural Morbidity and Outcomes

Neurosurgery ◽  
2000 ◽  
Vol 47 (6) ◽  
pp. 1320-1331 ◽  
Author(s):  
Gerasimos S. Baltsavias ◽  
James V. Byrne ◽  
Jim Halsey ◽  
Stuart C. Coley ◽  
Min-Joo Sohn ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Coil Embolization ◽  
Glasgow Outcome Scale ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
World Federation ◽  
Treatment Groups ◽  
Scale Scores ◽  
Group 3 ◽  
Group 2 ◽  
Group 1

ABSTRACT OBJECTIVE To elucidate the effect of treatment timing on procedural clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH) for patients treated by endosaccular coil embolization. METHODS A group of 327 patients who were consecutively treated, during a 46-month period, for ruptured intracranial aneurysms by coil embolization within 30 days after SAH were evaluated. Outcomes were assessed by comparing immediate pretreatment World Federation of Neurological Surgeons (WFNS) grades, 72-hour posttreatment WFNS grades, and modified Glasgow Outcome Scale scores at 6 months for patients treated within 48 hours (Group 1), 3 to 10 days (Group 2), or 11 to 30 days (Group 3) after SAH. RESULTS The three interval-to-treatment groups included 33, 38, and 29% of the patients, respectively. Before treatment, 70% of the patients in Group 1, 78% of those in Group 2, and 83% of those in Group 3 were in good clinical grades (i.e., WFNS Grade 1 or 2). After coil embolization, the WFNS grades were either unchanged or improved for 93.5% of the patients in Group 1, 89.5% of those in Group 2, and 91.5% of those in Group 3. After 6 months, 81.3% of the patients in Group 1 experienced good outcomes (modified Glasgow Outcome Scale scores of 1 or 2), as did 84% of those in Group 2 and 80% of those in Group 3. No statistical difference was demonstrated between the three groups when they were compared for these two variables. CONCLUSION The interval between endovascular treatment and SAH did not affect periprocedural morbidity rates or 6-month outcomes. Coil embolization should therefore be performed as early as possible after aneurysmal SAH, to prevent aneurysmal rerupture.

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.

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