M.H. Murad

Conscious Sedation versus General Anesthesia during Endovascular Acute Ischemic Stroke Treatment: A Systematic Review and Meta-Analysis

Nine studies encompassing nearly 2000 patients treated with or without anesthesia for acute stroke were analyzed. Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies. BACKGROUND AND PURPOSE: A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS: In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS: Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87–3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36–3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35–0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37–0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS: Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis.

Background: The Thrombolysis in Myocardial Infarction (TIMI) risk score uses clinical data to predict the short-term risk of acute myocardial infarction, coronary revascularization or death from any cause. It was originally developed for use in patients with unstable angina or non–ST-elevation myocardial infarction. We sought to expand the clinical application of the TIMI risk score by assessing its prognostic accuracy in patients in the emergency department with potential acute coronary syndromes. Methods: We searched five electronic databases, hand-searched reference lists of included studies and contacted content experts to identify articles for review. We included prospective cohort studies that validated the TIMI risk score in emergency department patients. We performed a meta-regression to determine whether a linear relation exists between TIMI risk score and the cumulative incidence of cardiac events. Results: We included 10 prospective cohort studies (with a total of 17 265 patients) in our systematic review. Data were available for meta-analysis in 8 of the 10 studies. Of patients with a score of zero, 1.8% had a cardiac event within 30 days (sensitivity 97.2%, 95% CI 96.4–97.8; specificity 25.0%, 95% CI 24.3–25.7; positive likelihood ratio 1.30, 95% CI 1.28–1.31; negative likelihood ratio 0.11, 95% CI 0.09–0.15). Meta-regression analysis revealed a strong linear relation between TIMI risk score (p < 0.001) and the cumulative incidence of cardiac events. Interpretation: Although the TIMI risk score is an effective risk stratification tool for patients in the emergency department with potential acute coronary syndromes, it should not be used as the sole means of determining patient disposition.

Accuracy and Quality of Clinical Decision Rules for Syncope in the Emergency Department: A Systematic Review and Meta-analysis

STUDY OBJECTIVE We assess the methodological quality and prognostic accuracy of clinical decision rules in emergency department (ED) syncope patients. METHODS We searched 6 electronic databases, reviewed reference lists of included studies, and contacted content experts to identify articles for review. Studies that derived or validated clinical decision rules in ED syncope patients were included. Two reviewers independently screened records for relevance, selected studies for inclusion, assessed study quality, and abstracted data. Random-effects meta-analysis was used to pool diagnostic performance estimates across studies that derived or validated the same clinical decision rule. Between-study heterogeneity was assessed with the I(2) statistic, and subgroup hypotheses were tested with a test of interaction. RESULTS We identified 18 eligible studies. Deficiencies in outcome (blinding) and interrater reliability assessment were the most common methodological weaknesses. Meta-analysis of the San Francisco Syncope Rule (sensitivity 86% [95% confidence interval {CI} 83% to 89%]; specificity 49% [95% CI 48% to 51%]) and the Osservatorio Epidemiologico sulla Sincope nel Lazio risk score (sensitivity 95% [95% CI 88% to 98%]; specificity 31% [95% CI 29% to 34%]). Subgroup analysis identified study design (prospective, diagnostic odds ratio 8.82 [95% CI 3.5 to 22] versus retrospective, diagnostic odds ratio 2.45 [95% CI 0.96 to 6.21]) and ECG determination (by evaluating physician, diagnostic odds ratio 25.5 [95% CI 4.41 to 148] versus researcher or cardiologist, diagnostic odds ratio 4 [95% CI 2.15 to 7.55]) as potential explanations for the variability in San Francisco Syncope Rule performance. CONCLUSION The methodological quality and prognostic accuracy of clinical decision rules for syncope are limited. Differences in study design and ECG interpretation may account for the variable prognostic performance of the San Francisco Syncope Rule when validated in different practice settings.

Deconstructive and Reconstructive Techniques in Treatment of Vertebrobasilar Dissecting Aneurysms: A Systematic Review and Meta-Analysis

Seventeen studies with 478 patients were included in this analysis, evaluating immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. Endovascular treatment of vertebrobasilar dissecting aneurysms showed high rates of complete occlusion and good long-term outcomes. BACKGROUND AND PURPOSE: Various endovascular techniques have been applied to the treatment of vertebrobasilar dissecting aneurysms, including parent artery preservation with coiling, stent placement or flow diverter placement, and trapping and proximal occlusion. We performed a systematic review and meta-analysis to study clinical and angiographic outcomes of patients undergoing endovascular treatment of vertebrobasilar dissecting aneurysms. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on the endovascular treatment of vertebrobasilar dissecting aneurysms. From each study we abstracted the following data: immediate occlusion, long-term occlusion, long-term good neurologic outcome, perioperative morbidity, perioperative mortality, rebleed (ruptured only), recurrence, and retreatment. We performed subgroup analyses of patients undergoing deconstructive-versus-reconstructive techniques. Meta-analysis was performed by using a random effects model. RESULTS: Seventeen studies with 478 patients were included in this analysis. Sixteen studies had at least 6 months of clinical/angiographic follow-up. Endovascular treatment was associated with high rates of long-term occlusion (87.0%; 95% CI, 74.0%–94.0%) and low recurrence (7.0%; 95% CI, 5.0%–10.0%) and retreatment rates (3.0%; 95% CI, 2.0%–6.0%). Long-term good neurologic outcome was 84.0% (95% CI, 65.0%–94.0%). Deconstructive techniques were associated with higher rates of long-term complete occlusion compared with reconstructive techniques (88.0%; 95% CI, 35.0%–99.0% versus 81.0%; 95% CI, 64.0%–91.0%; P < .0001). Deconstructive and reconstructive techniques were both associated with high rates of good neurologic outcome (86.0%; 95% CI, 68.0%–95.0% versus 92.0%; 95% CI, 86.0%–95.0%; P = .10). CONCLUSIONS: Endovascular treatment of vertebrobasilar dissecting aneurysms is associated with high rates of complete occlusion and good long-term neurologic outcomes. Deconstructive techniques are associated with higher occlusion rates. There was no statistical difference in neurologic outcomes between groups, possibly due to low power.

Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms: a meta-analysis.

The authors evaluated the results reported in 23 studies that included 516 patients in whom different drugs were used for rescue therapy in thromboembolic complications during endovascular treatment of intracranial aneurysms. The literature shows that rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab. BACKGROUND AND PURPOSE: Intraprocedural thrombus formation during endovascular treatment of intracranial aneurysms is often treated with glycoprotein IIb/IIIa inhibitors and, in some instances, fibrinolytic therapy. We performed a meta-analysis evaluating the safety and efficacy of GP IIb/IIIa inhibitors compared with fibrinolysis. We also evaluated the safety and efficacy of abciximab, an irreversible inhibitor, compared with tirofiban and eptifibatide, reversible inhibitors of platelet function. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on rescue therapy for intraprocedural thromboembolic complications with glycoprotein IIb/IIIa inhibitors or fibrinolysis during endovascular treatment of intracranial aneurysms. We studied rates of periprocedural stroke/hemorrhage, procedure-related morbidity and mortality, immediate arterial recanalization, and long-term good clinical outcome. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS: Twenty-three studies with 516 patients were included. Patients receiving GP IIb/IIIa inhibitors had significantly lower perioperative morbidity from stroke/hemorrhage compared with those treated with fibrinolytics (11.0%; 95% CI, 7.0%–16.0% versus 29.0%; 95% CI, 13.0%–55.0%; P = .04) and were significantly less likely to have long-term morbidity (16.0%; 95% CI, 11.0%–21.0% versus 35.0%; 95% CI, 17.0%–58.0%; P = .04). There was a trend toward higher recanalization rates among patients treated with glycoprotein IIb/IIIa inhibitors compared with those treated with fibrinolytics (72.0%; 95% CI, 64.0%–78.0% versus 50.0%; 95% CI, 28.0%–73.0%; P = .08). Patients receiving tirofiban or eptifibatide had significantly higher recanalization rates compared with those treated with abciximab (83.0%; 95% CI, 68.0%–91.0% versus 66.0%; 95% CI, 58.0%–74.0%; P = .05). No difference in recanalization was seen in patients receiving intra-arterial (77.0%; 95% CI, 66.0%–85.0%) or intravenous GP IIb/IIIa inhibitors (70.0%; 95% CI, 57.0%–80.0%, P = .36). CONCLUSIONS: Rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab.

Endovascular Treatment of Very Small Intracranial Aneurysms: Meta-Analysis

BACKGROUND AND PURPOSE: Outcomes of endovascular treatment of very small intracranial aneurysms are still not well-characterized. Recently, several series assessing coil embolization of tiny aneurysms have presented new promising results. Thus, we performed a systematic review and meta-analysis of studies evaluating endovascular treatment of very small intracranial aneurysms. MATERIALS AND METHODS: We conducted a computerized search of Scopus, Medline, and the Web of Science for studies on endovascular treatment of very small (≤3 mm in diameter) intracranial aneurysms published between January 1996 and May 2015. Using a random-effects model, we evaluated clinical and angiographic outcomes. RESULTS: Twenty-two studies with 1105 tiny aneurysms (844 ruptured and 261 unruptured) endovascularly treated were included. Postoperative and long-term complete occlusion was achieved in 85% (95% CI, 78%–90%) and 91% (95% CI, 87%–94%) of aneurysms, respectively. The recanalization rate was 6% (95% CI, 4%–11%) and retreatment occurred in 7% (95% CI, 5%–9%) of cases. Seventy-nine percent (95% CI, 64%–89%) of patients had good neurologic outcome at long-term follow-up. Intraprocedural rupture occurred in 7% (95% CI, 5%–9%) of the coiling procedures, while thromboembolic complications occurred in 4% (95% CI, 3%–6%). CONCLUSIONS: Coil embolization of very small intracranial aneurysms can be performed safely and effectively. In the case of unruptured aneurysms, procedure-related complications are not negligible. Patients and providers should consider such risks when engaged in a shared decision-making process.

Changing Clinical and Therapeutic Trends in Tentorial Dural Arteriovenous Fistulas: A Systematic Review

BACKGROUND AND PURPOSE: Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980–1995, 1996–2005, and 2006–2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities. RESULTS: Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980–1995 and 2006–2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%–91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%–83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%–95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%–87.0%; P = .03). CONCLUSIONS: Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rates.

Endovascular treatment of carotid blowout syndrome

Background: Carotid blowout syndrome (CBS) is a life‐threatening complication of head and neck cancer and radiation therapy. Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of CBS. We performed a systematic review and meta‐analysis to study periprocedural complications and outcomes of CBS patients treated with coil embolization and covered stents. Methods: A comprehensive literature search identified studies that reported outcomes of endovascular treatment of CBS published from 2000 to April 2016. Outcomes included technical success, postoperative rebleeding, survival time, and perioperative complications. Meta‐analyses were performed using a random‐effects model. Results: Twenty‐five noncomparative studies with 559 patients were included in the meta‐analysis. Technical success rate was 100% in both coiling and covered stenting groups. Median survival time was 3 months (range, 0–96 months) for all CBS patients. Overall perioperative mortality was 11% (95% confidence interval [CI], 5%‐17%). Postoperative rebleeding rate was 27% (95% CI, 19%‐367%). Perioperative stroke and infection rates were 3% (95% CI, 1%‐6%) and 1% (95% CI, 0%‐5%), respectively. At last follow‐up, 39% of patients were alive (95% CI, 29%‐48%). Conclusions: Coil embolization and stent grafts may both be safe treatment options for CBS with few perioperative complications and high rates of technical success, but prognosis after treatment remains poor. In general, noncomparative studies do not demonstrate differences between the two techniques with respect to periprocedural complications and patient outcomes.

Diffusion-Weighted Imaging–Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE: Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms. MATERIALS AND METHODS: A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model. RESULTS: Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%–56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%–85%; versus 45%; 95% CI, 33%–56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%–60%; P = .99) or stent-assisted (43%; 95% CI, 24%–63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions. CONCLUSIONS: One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events.

Endovascular treatment of internal carotid artery bifurcation aneurysms: a single-center experience and a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Endovascular coiling of internal carotid artery bifurcation aneurysms can be challenging due to unfavorable morphologic features. With improvements in endovascular techniques, several series have detailed the results and complications of endovascular treatment of aneurysms at this location. We performed a systematic review and meta-analysis of published series on the endovascular treatment of ICA bifurcation aneurysms, including a tertiary referral center experience. MATERIALS AND METHODS: We performed a comprehensive literature search for reports on contemporary endovascular treatment of ICA bifurcation aneurysms from 2000 to 2013, and we reviewed our experience. We extracted information regarding periprocedural complications, procedure-related morbidity and mortality, immediate angiographic outcome, long-term clinical and angiographic outcome, and retreatment rate. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS: Including our series of 37 patients, 6 studies with 158 patients were analyzed. Approximately 60% of the aneurysms presented as unruptured; 88.0% (95% CI, 68.0%–96.0%) of aneurysms showed complete or near-complete occlusion at immediate postoperative angiography compared with 82.0% (95% CI, 73.0%–88.0%) at last follow-up. The procedure-related morbidity and mortality were 3.0% (95% CI, 1.0%–7.0%) and 3.0% (95% CI, 1.0%–8.0%), respectively. The retreatment rate was 14.0% (95% CI, 8.0%–25.0%). Good neurologic outcome was achieved in 93.0% (95% CI, 86.0%–97.0%) of patients. CONCLUSIONS: Endovascular treatment of ICA bifurcation aneurysms is feasible and effective and is associated with high immediate angiographic occlusion rates. However, retreatment rates and procedure-related morbidity and mortality are non-negligible.