Stroke; a journal of cerebral circulation
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Meta Analysis
Perioperative/Postoperative Atrial Fibrillation and Risk of Subsequent Stroke and/or Mortality.
Background and Purpose- Although believed to be transient and self-limiting, new-onset perioperative/postoperative atrial fibrillation (POAF) might be a risk factor for stroke and mortality. We conducted a systematic review and meta-analysis to qualitatively and quantitatively evaluate the relationship of POAF with early and late risks of mortality and stroke. Methods- We searched Pubmed, EMBASE, and Cochrane Library (1966 through March 2018) to identify cohort studies that reported stroke and mortality associated with POAF. ⋯ In subgroup analyses, POAF was more strongly associated with stroke in patients undergoing noncardiac surgery (HR, 2.00; 95% CI, 1.70-2.35) than in patients undergoing cardiac surgery (HR, 1.20; 95% CI, 1.07-1.34). Conclusions- New-onset POAF is associated with an increased risk of stroke and mortality, both in the short-term and long-term. The best strategy to reduce stroke risk among these patients needs to be determined.
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Background and Purpose- We sought to evaluate the available literature to determine whether primary seizure prevention with antiepileptic drugs reduces the risk of poor outcomes and clinically relevant seizures among adult patients with spontaneous intracerebral hemorrhage. Methods- Meta-analysis of observational studies and randomized controlled trials evaluating the use of any antiepileptic drug for primary seizure prevention among adult (≥18 years) patients with spontaneous intracerebral hemorrhage. The primary end point was poor clinical outcome at the longest recorded follow-up, defined as either a high (>3) modified Rankin Scale score or all-cause mortality during follow-up if the modified Rankin Scale score was not recorded. ⋯ Overall, the use of antiepileptic drugs was not associated with a high Rankin Scale or all-cause mortality (odds ratio: 0.99; 95% CI, 0.66-1.49) or incident seizures (odds ratio: 0.89; 95% CI, 0.52-1.51) at the longest recorded follow-up time. Conclusions- The use of antiepileptic drugs as primary prevention among adult patients with spontaneous intracerebral hemorrhage is not associated with improved neurological function during long-term follow-up. Future studies should focus on the preventive use of distinct antiepileptic agents among patients at high risk of both seizures and poor outcomes.
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Meta Analysis
Optimal Duration of Aspirin Plus Clopidogrel After Ischemic Stroke or Transient Ischemic Attack.
Background and Purpose- The role of aspirin plus clopidogrel (A+C) therapy compared with aspirin monotherapy in patients presenting with acute ischemic stroke (IS) or transient ischemic attack remains uncertain. We conducted this study to determine the optimal period of efficacy and safety of A+C compared with aspirin monotherapy. Methods- Ten randomized controlled trials (15 434 patients) were selected using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (inception June 2018) comparing A+C with aspirin monotherapy in patients with transient ischemic attack or IS. ⋯ Intermediate-term (RR, 2.58; 95% CI, 1.19-5.60) and long-term (RR, 1.87; 95% CI, 1.36-2.56) A+C regimens significantly increased the risk of major bleeding as opposed to short-term A+C (RR, 1.82; 95% CI, 0.91-3.62). Excessive all-cause mortality was limited to long-term A+C (RR, 1.45; 95% CI, 1.10-1.93). Conclusions- Short-term A+C is more effective and equally safe in comparison to aspirin alone in patients with acute IS or transient ischemic attack.
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Background and Purpose- Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis. Methods- Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. ⋯ We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22-0.59) and 0.59 (0.34-1.00) for evacuations performed within 24 hours and 0.49 (0.38-0.63) and 0.57 (0.43-0.76) for evacuations performed within 72 hours. Conclusions- This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.
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Background and Purpose- The role of recanalization of the occluded dural sinus or vein in the outcome of patients with cerebral venous thrombosis (CVT) is not established. We aimed to systematically review, in patients with CVT, (1) the recanalization rate and its association with (2) clinical outcome and (3) CVT recurrence. Methods- Systematic search in MEDLINE (Medical Literature Analysis and Retrieval System Online), Cochrane Library, and clinicaltrials.gov (inception to September 2017). ⋯ In studies with higher methodological quality, the recanalization rate was 77% (95% confidence interval, 70-82; I2=0%). (2) There was a significant increase in the chance of favorable outcome (modified Rankin scale, 0-1) in patients with recanalization with a pooled odds ratio of 3.3 (95% confidence interval, 1.2-8.9; I2=32%) in the random effects meta-analysis and a common odds ratio of 3.3 (95% confidence interval, 1.7-6.3) in the ordinal logistic regression. (3) Data on CVT recurrence according to recanalization was scarce. Conclusions- The overall rate of recanalization in patients receiving anticoagulation was 85%, but exclusion of severe patients from follow-up imaging is a plausible source of bias. Lack of venous recanalization was associated with worse clinical outcome.