-
Neurosurgical Review Jan 2023Multiple brain arteriovenous malformations (bAVM) are rare neurovascular lesions usually related to genetic syndromes. Its management is not well established given its... (Meta-Analysis)
Meta-Analysis
Multiple brain arteriovenous malformations (bAVM) are rare neurovascular lesions usually related to genetic syndromes. Its management is not well established given its rarity. The objective of this study was to describe the clinical and angiographic features of published cases and to explore their associations with treatment outcomes. We performed a literature search of published cases in Medline and the Regional Index Medici. Additional cases were searched in our single-center registry. Data on the proportions of patients and clinical and angiographic characteristics were extracted. The study outcomes were nidal instability in patients who underwent staged treatment and radiological cure in patients who underwent treatment using any treatment modality. Logistic regression models for the study outcomes were analyzed. Data on the proportions of multiple bAVM patients were summarized with meta-analyses of proportions. We included 118 patients (reported in 68 studies) from the literature and 6 cases identified in our registry. A total of 124 patients harboring 339 bAVM nidi were included in the analyses. Differences between syndromic and non-syndromic cases were observed. The logistic regression analyses showed that angiographically occult untreated bAVM was associated (OR 14.37; 95% CI 2.17 to 95.4) with nidal instability after staged treatment, and deep (OR 5.11; 95% CI 1.51 to 17.27) and eloquent (OR 3.91; 95% CI 1.22 to 12.52) locations were associated with residual disease after treatment. Inconsistent reporting of relevant data throughout the included studies undermined the planned analyses. Some prognostic factors were found to be related to the study outcomes. Study Registration: The protocol of the systematic review was registered in PROSPERO as CRD42021245814.
Topics: Humans; Intracranial Arteriovenous Malformations; Brain; Treatment Outcome; Angiography
PubMed: 36708432
DOI: 10.1007/s10143-023-01951-3 -
Plastic and Reconstructive Surgery Jan 2016Vascular malformations are congenital anomalies of the vascular system. Intralesional bleomycin injections are commonly used to treat vascular malformations. However,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Vascular malformations are congenital anomalies of the vascular system. Intralesional bleomycin injections are commonly used to treat vascular malformations. However, pulmonary fibrosis could potentially be a severe complication, known from systemic bleomycin therapy for malignancies. In this study, the authors investigate the effectiveness and safety of bleomycin (A2, B2, and A5) injections for vascular malformations, when possible relative to other sclerosants.
METHODS
The authors performed a PubMed, Embase, Cochrane Central Register of Controlled Trials, and gray literature search for studies (1995 to the present) reporting outcome of intralesional bleomycin injections in patients with vascular malformations (n ≥ 10). Predefined outcome measures of interest were size reduction, symptom relief, quality of life, adverse events (including pulmonary fibrosis), and patient satisfaction.
RESULTS
Twenty-seven studies enrolling 1325 patients were included. Quality of evidence was generally low. Good to excellent size reduction was reported in 84 percent of lymphatic and 87 percent of venous malformations. Pulmonary fibrosis was never encountered. Meta-analysis of four studies on venous malformations treated with bleomycin versus other sclerosants showed similar size reduction (OR, 0.67; 95 percent CI, 0.24 to 1.88) but a significantly lower adverse event rate (OR, 0.1; 95 percent CI, 0.03 to 0.39) and fewer severe complications after bleomycin. Symptom relief, quality of life, and patient satisfaction were reported inadequately.
CONCLUSIONS
The authors' data suggest that bleomycin is effective in reducing the size of lymphatic and venous malformations, and leads to a lower adverse event rate and fewer severe complications than other sclerosants. The included literature does not provide evidence that pulmonary fibrosis is a complication of intralesional bleomycin injections. This study represents the "best available" evidence; however, only low- to moderate-quality studies were available.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, IV.
Topics: Angiography; Bleomycin; Female; Follow-Up Studies; Humans; Injections, Intralesional; Male; Netherlands; Risk Assessment; Severity of Illness Index; Treatment Outcome; Vascular Malformations
PubMed: 26710030
DOI: 10.1097/PRS.0000000000001924 -
Resuscitation Mar 2021Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an... (Meta-Analysis)
Meta-Analysis Review
Diagnostic test accuracy of the initial electrocardiogram after resuscitation from cardiac arrest to indicate invasive coronary angiographic findings and attempted revascularization: A systematic review and meta-analysis.
AIM
Conduct a diagnostic test accuracy systematic review and meta-analysis of the post-return of spontaneous circulation (ROSC) electrocardiogram (ECG) to indicate an acute-appearing coronary lesion and revascularization.
METHODS
We searched PubMed, EMBASE, CINAHL, Cochrane Library, and Web of Science through February 18, 2020. Two investigators screened titles and abstracts, extracted data, and assessed risks of bias using QUADAS-2. We estimated sensitivity (Sn), specificity (Sp), and likelihood ratios (LR) for all reported ECG features to indicate all reported reference standards. Random-effects meta-analysis pooled comparable studies without critical risk of bias. GRADE methodology evaluated the certainty of evidence.
RESULTS
Overall, 48 studies reported 94 combinations of ECG features and reference standards with wide variation in their definitions. Most studies had risks of bias from selection for coronary angiography and blinding to the ECG and/or reference standard. Meta-analysis combined 6 studies for STE and acute coronary lesion (Sn 0.70 [95% CI 0.54-0.82]; Sp 0.85 [95% CI 0.78-0.90]; LR + 4.7 [95% CI 3.3-6.7]; LR- 0.4 [95% CI 0.2-0.6]) and 4 studies for STE and revascularization (Sn 0.53 [95% CI 0.47-0.58]; Sp 0.86 [95% CI 0.80-0.91]; LR + 3.9 [95% CI 2.8-5.5]; LR- 0.5 [95% CI 0.5-0.6]). Overall certainty of evidence was low with substantial heterogeneity.
CONCLUSIONS
Based on low certainty evidence, STE had good classification for acute coronary lesion and fair classification for revascularization. STE was more specific than sensitive for these outcomes and no single ECG feature excluded them. Uniform definitions and terminology would greatly facilitate the interpretation of subsequent studies.
Topics: Coronary Angiography; Diagnostic Tests, Routine; Electrocardiography; Heart Arrest; Humans; Sensitivity and Specificity
PubMed: 33444708
DOI: 10.1016/j.resuscitation.2020.11.039 -
Acta Ophthalmologica May 2024Central serous chorioretinopathy (CSC) is a prevalent exudative maculopathy and the ongoing verteporfin shortage restricts current treatment possibilities. Topical... (Meta-Analysis)
Meta-Analysis Review
Central serous chorioretinopathy (CSC) is a prevalent exudative maculopathy and the ongoing verteporfin shortage restricts current treatment possibilities. Topical non-steroidal anti-inflammatory drugs (NSAID) have previously been proposed as a treatment for CSC, although its exact efficacy remains unclear. In this systematic review and meta-analysis, we outlined the efficacy of topical NSAIDs for the treatment of CSC. We searched 11 literature databases on 13 December 2022, for any study describing topical NSAID treatment for CSC. Thirteen eligible studies were included with a total of 1001 eyes of 994 patients with CSC. Six studies were case reports, two were cohort studies and five were non-randomized comparative studies. Where specified, topical NSAIDs used were bromfenac 0.09%, diclofenac 0.1%, ketorolac 0.4% and 0.5%, pranoprofen 0.1%, and nepafenac 0.1% and 0.3%. Studies were predominantly of cases with acute CSC and several case studies reported treatment outcomes simultaneously with discontinuation of corticosteroid use, which complicated treatment evaluation. Meta-analyses of comparative studies revealed a statistically significant but clinically irrelevant best-corrected visual acuity improvement of -0.04 logMAR (95% CI: -0.07 to -0.01 logMAR; p = 0.01) at 1-month follow-up, which became statistically insignificant at 3-month follow-up (-0.03 logMAR; 95% CI: -0.06 to 0.003 logMAR; p = 0.08). Further, we found no benefit in complete subretinal fluid resolution at 1-month follow-up (OR: 1.20; 95% CI: 0.81-1.76; p = 0.37) or 3-month follow-up (OR: 1.17; 95% CI: 0.86 to 1.59; p = 0.33). Taken together, available evidence does not support the use of topical NSAIDs for the treatment of CSC.
Topics: Humans; Central Serous Chorioretinopathy; Treatment Outcome; Verteporfin; Photochemotherapy; Anti-Inflammatory Agents, Non-Steroidal; Tomography, Optical Coherence; Fluorescein Angiography
PubMed: 37551858
DOI: 10.1111/aos.15743 -
Microsurgery Sep 2023Indocyanine green angiography (ICG-A) has been widely applied for intraoperative flap assessment in DIEP flap breast reconstruction. However, the beneficial effect of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Indocyanine green angiography (ICG-A) has been widely applied for intraoperative flap assessment in DIEP flap breast reconstruction. However, the beneficial effect of ICG-A in DIEP flap breast reconstruction is still uncertain and no standardized protocol is available. This study aims to analyze the clinical outcome and comprehensively review protocols of this field.
METHODS
A systematic review was conducted in MEDLINE, EMBASE, and Cochrane CENTRAL databases until September 15, 2022. Studies on the utility of intraoperative ICG-A in DIEP breast reconstruction were included. Data reporting reconstruction outcomes were extracted for pooled analysis.
RESULTS
A total of 22 studies were enrolled in the review, among five studies with 1021 patients included in the meta-analysis. The protocols of ICG-A assessment of DIEP flap varied among studies. According to the pooled results, the incidence of postoperative fat necrosis was 10.89% (50 of 459 patients) with ICG-A and 21.53% (121 of 562 patients) with clinical judgment. The risk for postoperative fat necrosis was significantly lower in patients with intraoperative ICG-A than without (RR 0.47 95% CI 0.29-0.78, p = .004, I = 51%). Reoperation occurred in 5 of 48 patients (10.42%) in the ICG-A group and in 21 of 64 patients (32.82%) in the control group summarized from reports in two studies. The risk for reoperation was lower in the ICG-A group than in the control group (RR 0.41 95% CI 0.18-0.93, p = .03, I = 0%). Other complications, including flap loss, seroma, hematoma, dehiscence, mastectomy skin necrosis, and infection, were comparable between the two groups. Heterogeneities among studies were acceptable. No significant influence of specific studies was identified in sensitivity analysis.
CONCLUSIONS
ICG-A is an accurate and reliable way to identify problematic perfusion of DIEP flaps during breast reconstruction. Protocols of ICG-A differed in current studies. Intraoperative ICG-A significantly decreases the rate of fat necrosis and reoperation in patients undergoing DIEP breast reconstruction. The synthesized results should be interpreted sensibly due to the sample size limitation. RCTs on the outcomes and high-quality studies for an optimized ICG-A protocol are still needed in the future.
Topics: Humans; Female; Mastectomy; Indocyanine Green; Perforator Flap; Fat Necrosis; Breast Neoplasms; Mammaplasty; Angiography; Perfusion; Postoperative Complications; Epigastric Arteries; Retrospective Studies
PubMed: 37165852
DOI: 10.1002/micr.31056 -
Alimentary Pharmacology & Therapeutics Nov 2009Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents... (Comparative Study)
Comparative Study Review
BACKGROUND
Invasive measurement of the hepatic venous pressure gradient (HVPG) is regarded as the gold standard for risk stratification and the evaluation of pharmaceutical agents in patients with portal hypertension.
AIM
To review the techniques for endoscopic and imaging-based assessment of portal haemodynamics, with particular emphasis on trials where the results were compared with HVPG or direct portal pressure measurement.
METHODS
Systematic search of the MEDLINE electronic database with keywords: portal hypertension, variceal bleeding, variceal pressure, endoscopic ultrasound, Doppler ultrasonography, magnetic resonance angiography, CT angiography, hepatic venous pressure gradient.
RESULTS
Computed tomography angiography and endoscopic ultrasound (EUS) have been both employed for the diagnosis of complications of portal hypertension and for the evaluation of the efficacy of endoscopic therapy. Colour Doppler ultrasonography and magnetic resonance angiography has given discrepant results. Endoscopic variceal pressure measurements either alone or combined with simultaneous EUS, correlate well with HVPG and risk of variceal bleeding and have a low interobserver variability.
CONCLUSIONS
Endoscopic and imaging-based measurements of portal haemodynamics provide an alternate means for the assessment of complications of portal hypertension. Further studies are required to validate their use in risk stratification and the evaluation of drug therapies in patients with portal hypertension.
Topics: Endoscopy; Esophageal and Gastric Varices; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Magnetic Resonance Angiography; Portal Pressure; Portal System; Risk Factors; Ultrasonography, Doppler
PubMed: 19735231
DOI: 10.1111/j.1365-2036.2009.04135.x -
The Spine Journal : Official Journal of... Oct 2022Prior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
Prior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs.
PURPOSE
The aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA.
STUDY DESIGN/SETTING
Systematic review and meta-analysis.
OUTCOME MEASURES
Odds ratios for specific cervical fracture patterns and risk of developing a BCVI.
METHODS
A systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA).
RESULTS
The initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1-C3 fracture, any C4-C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1-C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4-C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8-2.1); C2: 1.6 (0.9-2.8); C3: 1.8 (0.9-3.6); C1-C3: 2.2 (1.1-4.2); C4-C7: 0.7 (0.3-1.7); Two-level: 2.5 (1.4-4.6); Subluxation/Dislocation: 2.9 (1.8-4.5); TF: 3.6 (1.4-8.9).
DISCUSSION/CONCLUSION
This study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.
Topics: Adolescent; Adult; Angiography; Cerebrovascular Trauma; Child; Computed Tomography Angiography; Humans; Joint Dislocations; Retrospective Studies; Spinal Fractures; Tomography, X-Ray Computed; Wounds, Nonpenetrating
PubMed: 35671944
DOI: 10.1016/j.spinee.2022.05.009 -
The British Journal of Surgery Apr 2012Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate,... (Review)
Review
BACKGROUND
Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.
METHODS
A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.
RESULTS
Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.
CONCLUSION
Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.
Topics: Abdomen; Angiography; Aorta; Arm; Humans; Leg; Magnetic Resonance Angiography; Neck; Sensitivity and Specificity; Tomography, X-Ray Computed; Ultrasonography, Doppler, Duplex; Vascular System Injuries; Wounds, Nonpenetrating; Wounds, Penetrating
PubMed: 22190106
DOI: 10.1002/bjs.7763 -
Journal of Cerebral Blood Flow and... Feb 2014Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool... (Meta-Analysis)
Meta-Analysis Review
Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool is needed. We performed a systematic review to evaluate the value of CT perfusion (CTP) in the prediction and diagnosis of DCI. We searched PubMed, Embase, and Cochrane databases to identify studies on the relationship between CTP and DCI. Eleven studies totaling 570 patients were included. On admission, cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-peak (TTP) did not differ between patients who did and did not develop DCI. In the DCI time-window (4 to 14 days after subarachnoid hemorrhage (SAH)), DCI was associated with a decreased CBF (pooled mean difference -11.9 mL/100 g per minute (95% confidence interval (CI): -15.2 to -8.6)) and an increased MTT (pooled mean difference 1.5 seconds (0.9-2.2)). Cerebral blood volume did not differ and TTP was rarely reported. Perfusion thresholds reported in studies were comparable, although the corresponding test characteristics were moderate and differed between studies. We conclude that CTP can be used in the diagnosis but not in the prediction of DCI. A need exists to standardize the method for measuring perfusion with CTP after SAH, and optimize and validate perfusion thresholds.
Topics: Blood Flow Velocity; Brain Ischemia; Cerebral Angiography; Cerebrovascular Circulation; Female; Humans; Intracranial Aneurysm; Male; PubMed; Subarachnoid Hemorrhage; Tomography, X-Ray Computed
PubMed: 24281744
DOI: 10.1038/jcbfm.2013.208 -
European Radiology Nov 2013To evaluate the diagnostic performance of computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting... (Meta-Analysis)
Meta-Analysis Review
Diagnostic performance of computed tomography angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic review and meta-analysis.
OBJECTIVE
To evaluate the diagnostic performance of computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting haemodynamically significant arterial stenosis or occlusion in patients with critical limb ischaemia (CLI) or intermittent claudication (IC).
METHODS
Medline and Embase were searched for studies comparing CTA or CE-MRA with digital subtraction angiography as a reference standard, including patients with CLI or IC. Outcome measures were aortotibial arterial stenosis of more than 50 % or occlusion. Methodological quality of studies was assessed using QUADAS.
RESULTS
Out of 5,693 articles, 12 CTA and 30 CE-MRA studies were included, respectively evaluating 673 and 1,404 participants. Summary estimates of sensitivity and specificity were respectively 96 % (95 % CI, 93-98 %) and 95 % (95 % CI, 92-97 %) for CTA, and 93 % (95 % CI, 91-95 %) and 94 % (95 % CI, 93-96 %) for CE-MRA. Regression analysis showed that the prevalence of CLI in individual studies was not an independent predictor of sensitivity and specificity for either technique. Methodological quality of studies was moderate to good.
CONCLUSION
CTA and CE-MRA are accurate techniques for evaluating disease severity of aortotibial arteries in patients with CLI or IC. No significant differences in the diagnostic performance of the two techniques between patients with CLI and IC were found.
KEY POINTS
• Computed tomography and contrast-enhanced magnetic resonance angiography can both demonstrate arterial disease. • CTA and CE-MRA can both accurately evaluate arteries in peripheral arterial disease. • Diagnostic performances of critical limb ischaemia and intermittent claudication are not different. • Separate imaging technique of tibial arteries by CE-MRA is preferred. • CTA and CE-MRA can distinguish confidently between high-grade stenoses and occlusions.
Topics: Angiography; Angiography, Digital Subtraction; Contrast Media; Humans; Intermittent Claudication; Ischemia; Leg; Magnetic Resonance Angiography; Reproducibility of Results; Tomography, X-Ray Computed
PubMed: 23801421
DOI: 10.1007/s00330-013-2933-8