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Journal of Neurology, Neurosurgery, and... Oct 2008Cervical dissection is an important cause of stroke in the young. This paper presents a systematic review and a meta-analysis to assess the effectiveness of different... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Cervical dissection is an important cause of stroke in the young. This paper presents a systematic review and a meta-analysis to assess the effectiveness of different treatment approaches: antithrombotic drugs, thrombolysis and stenting.
METHODS
Medline and PubMed were searched from 1966 to 8 April 2007. Reference lists were reviewed. Separate searches were performed for treatment with anticoagulation and antiplatelet therapy during the acute phase (within 1 month of symptoms), thrombolysis and stenting.
RESULTS
There were only sufficient data for meta-analysis for the comparison of antiplatelet versus anticoagulation therapy. No randomised trials were identified. 34 non-randomised studies included 762 patients. There was no significant difference in risk of death (antiplatelet 5/268 (1.8%), anticoagulation 9/494 (1.8%), p = 0.88); stroke (antiplatelet 5/268 (1.9%), anticoagulant 10/494 (2.0%), p = 0.66), or stroke and death. Four non-randomised studies of thrombolysis provided insufficient data for assessment of efficacy but complication rates were no greater than thrombolysis for other ischaemic stroke. Six studies included 96 patients undergoing stenting for both acute dissection and chronic complications, providing insufficient data for assessment of efficacy, although complication rates appeared similar to those published for carotid atherosclerosic stenosis.
CONCLUSIONS
There are no data to support the therapeutic superiority of anticoagulants over antiplatelet agents. Thrombolysis in dissection appears safe but more data on efficacy are required. Stenting is technically possible but there are no data to demonstrate efficacy. There is little evidence to support current treatment approaches in cervical dissection. Randomised controlled prospective trials, particularly assessing anticoagulation versus antiplatelet agents, are required.
Topics: Acute Disease; Combined Modality Therapy; Fibrinolytic Agents; Humans; Neurosurgical Procedures; Platelet Aggregation Inhibitors; Stents; Vertebral Artery Dissection; Vertebrobasilar Insufficiency
PubMed: 18303104
DOI: 10.1136/jnnp.2007.138800 -
JAMA Neurology Jun 2024Cervical artery dissection is the most common cause of stroke in younger adults. To date, there is no conclusive evidence on which antithrombotic therapy should be used... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Cervical artery dissection is the most common cause of stroke in younger adults. To date, there is no conclusive evidence on which antithrombotic therapy should be used to treat patients.
OBJECTIVE
To perform an individual patient data meta-analysis of randomized clinical trials comparing anticoagulants and antiplatelets in prevention of stroke after cervical artery dissection.
DATA SOURCES
PubMed.gov, Cochrane database, Embase, and ClinicalTrials.gov were searched from inception to August 1, 2023.
STUDY SELECTION
Randomized clinical trials that investigated the effectiveness and safety of antithrombotic treatment (antiplatelets vs anticoagulation) in patients with cervical artery dissection were included in the meta-analysis. The primary end point was required to include a composite of (1) any stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up.
DATA EXTRACTION/SYNTHESIS
Two independent investigators performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and inconsistencies were resolved by a principal investigator.
MAIN OUTCOMES AND MEASURES
The primary outcome was a composite of (1) ischemic stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up. The components of the composite outcome were also secondary outcomes. Subgroup analyses based on baseline characteristics with a putative association with the outcome were performed. Logistic regression was performed using the maximum penalized likelihood method including interaction in the subgroup analyses.
RESULTS
Two randomized clinical trials, Cervical Artery Dissection in Stroke Study and Cervical Artery Dissection in Stroke Study and the Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection, were identified, of which all participants were eligible. A total of 444 patients were included in the intention-to-treat population and 370 patients were included in the per-protocol population. Baseline characteristics were balanced. There were fewer primary end points in those randomized to anticoagulation vs antiplatelet therapy (3 of 218 [1.4%] vs 10 of 226 [4.4%]; odds ratio [OR], 0.33 [95% CI, 0.08-1.05]; P = .06), but the finding was not statistically significant. In comparison with aspirin, anticoagulation was associated with fewer strokes (1 of 218 [0.5%] vs 10 of 226 [4.0%]; OR, 0.14 [95% CI, 0.02-0.61]; P = .01) and more bleeding events (2 vs 0).
CONCLUSIONS AND RELEVANCE
This individual patient data meta-analysis of 2 currently available randomized clinical trial data found no significant difference between anticoagulants and antiplatelets in preventing early recurrent events.
Topics: Humans; Vertebral Artery Dissection; Fibrinolytic Agents; Platelet Aggregation Inhibitors; Anticoagulants; Randomized Controlled Trials as Topic; Stroke; Carotid Artery, Internal, Dissection
PubMed: 38739383
DOI: 10.1001/jamaneurol.2024.1141 -
Journal of Stroke and Cerebrovascular... Mar 2014The purpose of this meta-analysis is to compare clinical outcomes between endovascular treatment and conservative treatment for cervicocranial artery dissection. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The purpose of this meta-analysis is to compare clinical outcomes between endovascular treatment and conservative treatment for cervicocranial artery dissection.
METHODS
Medline, Embase, and Cochrane Library databases were searched for studies comparing endovascular treatment versus conservative treatment for cervicocranial artery dissection patients. The period searched was from November 1994 to March 2013. Fifteen observational studies involving 442 cervicocranial artery dissection patients were found. Evaluated outcomes included rate of mortality, disability, and good recovery. The rebleeding rate in subarachnoid hemorrhage (SAH) patients was also recorded and compared.
RESULTS
In general, patients who received endovascular treatment enjoyed a lower mortality rate than those who received conservative treatment (P = .02, odds ratio [OR]: .5, 95% confidence interval [CI]: .27-.90), especially patients having ruptured cervicocranial artery dissection (P = .002, OR: .32, 95% CI .15-.66) and dissecting aneurysms (P = .006, OR: .31, 95% CI .14-.71). Among SAH patients with a Hunt-Hess score of 3 or more, endovascular treatment decreased mortality significantly (P = .006, OR: .22, 95% CI .08-.65), whereas no significant differences between these 2 treatments occurred in patients having a Hunt-Hess score less than 3.
CONCLUSIONS
Endovascular treatment yields a better outcome, with greater benefit in patients with ruptured cervicocranial artery dissection, dissecting aneurysms, and a Hunt-Hess score of 3 or more. Randomized controlled trials comparing these 2 therapeutic strategies are needed.
Topics: Aortic Dissection; Aneurysm, Ruptured; Chi-Square Distribution; Disability Evaluation; Endovascular Procedures; Humans; Intracranial Aneurysm; Odds Ratio; Patient Selection; Risk Assessment; Risk Factors; Subarachnoid Hemorrhage; Treatment Outcome
PubMed: 24231136
DOI: 10.1016/j.jstrokecerebrovasdis.2013.09.026 -
Journal of the American Heart... Sep 2017Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post-TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post-TEVAR.
METHODS AND RESULTS
Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0-3.1) and 37.1% (95% CI, 23.7-51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (=0.043), history of vascular surgery (=0.042), and American Surgical Association (=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04-3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70-10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22-3.50). RTAD occurrence rate in zone 0 was higher than other landing zones.
CONCLUSIONS
The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more-experienced centers tend to have lower RTAD incidences.
Topics: Aged; Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Incidence; Male; Metals; Middle Aged; Odds Ratio; Prosthesis Design; Risk Factors; Stents; Treatment Outcome
PubMed: 28939705
DOI: 10.1161/JAHA.116.004649 -
Dermatology and Therapy Nov 2023Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory skin condition characterized by abscesses, nodules, fistulas, and scarring alopecia. Management of... (Review)
Review
BACKGROUND
Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory skin condition characterized by abscesses, nodules, fistulas, and scarring alopecia. Management of this oftentimes debilitating dermatosis can be challenging due to its recalcitrant nature. There is limited data regarding the efficacy of treatment options for DCS.
OBJECTIVE
The aim of this study was to conduct a systematic review of the literature to explore the efficacy and safety of reported DCS treatments.
METHODS
In October 2022, MEDLINE and EMBASE databases were searched for articles on treatments for DCS. Studies that contained outcome efficacy data for DCS treatments were included. Reviews, conference abstracts, meta-analyses, commentaries, non-relevant articles, and articles with no full-text available were excluded. Data extraction was performed by two independent reviewers.
RESULTS
A total of 110 relevant articles with 417 patients were identified. A majority of studies (86.4%) were case reports or series. Treatment options included systemic antibiotics, oral retinoids, biologics, procedural treatments, combination agents, and topical treatments. Oral retinoids and photodynamic therapy were the most extensively studied medical and procedural interventions, respectively.
CONCLUSION
Overall, randomized controlled trials are needed to evaluate various treatment regimens for DCS and provide patients with a robust, evidence-based approach to therapy.
PubMed: 37740150
DOI: 10.1007/s13555-023-01018-7 -
Journal of Oral Pathology & Medicine :... Feb 2021To estimate the rate of occult cervical lymph node metastases in cN0 patients affected by primary parotid carcinomas and to scrutinize the evidence on the indication and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
To estimate the rate of occult cervical lymph node metastases in cN0 patients affected by primary parotid carcinomas and to scrutinize the evidence on the indication and extent of elective neck dissection in these neoplasms.
METHODS
Medline, Embase, Web of Science, Cochrane Library and Scopus were searched until August 31, 2020, to identify studies reporting the use of elective neck dissection in the management of malignant parotid tumours. The PRISMA checklist was used. A single arm meta-analysis was then made to determine the pooled rate of occult lymph node metastases. Risk of bias of the included studies was assessed through the ROBINS-E tool.
RESULTS
The initial search returned 20 541 articles, of which twelve met the inclusion criteria and were included in the meta-analysis. They comprised 1310 patients with parotid carcinoma, of whom 542 cN0 underwent elective neck dissection, which led to the diagnosis of lymph node metastasis (pN+/cN0) in 113 cases. Meta-analysis of the results of elective neck dissection showed an overall rate of occult metastases of 0.22 (99% CI: 0.14-0.30). Locally advanced or high-grade tumours were the commonest indications for elective neck dissection in the included studies. The most dissected lymph node levels were I-II-III, and level II was the commonest site of occult nodal metastases.
CONCLUSIONS
An occult metastasis rate of 0.22 (99% CI: 0.14-0.30) represents a not negligible percentage value, which should encourage further research to outline the most appropriate elective neck management in cN0 patients with parotid carcinomas.
Topics: Carcinoma; Humans; Lymph Nodes; Lymphatic Metastasis; Neck Dissection; Neoplasm Staging; Parotid Neoplasms; Retrospective Studies
PubMed: 33222323
DOI: 10.1111/jop.13137 -
International Journal of Cardiology Jan 2019To investigate the association between fluoroquinolones use and development of aortopathy. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate the association between fluoroquinolones use and development of aortopathy.
METHODS
A systematic review and meta-analysis was conducted following PRISMA and MOOSE guidelines for reporting systematic reviews of observational studies. Multiple databases were searched and two authors independently screened studies for eligibility. Newcastle Ottawa scale was used to assessed the quality of included studies. Primary outcome of interest was development of aortic aneurysm or dissection among fluoroquinolones users in comparison to non-users. An inverse variance model meta-analysis was used to pool odds ratio or hazards ratio from included studies to calculate the overall effect estimate. Pre specified subgroups analyses were also conducted to explore sources of heterogeneity.
RESULTS
Three observational studies that enrolled 941,639 subjects met the inclusion criteria and were included in the final analysis. All studies were of a good methodological quality. Current use of fluoroquinolones, defined as within 60 days from development of the primary outcome, was associated with significantly elevated risk of developing aortic aneurysm and/or dissection in comparison to controls, (OR = 2.04; 95% CI [1.67, 2.48]). There was only a mild degree of between study heterogeneity, I = 33%. The association remains robust among all subgroups analyses.
CONCLUSION
Our findings indicate that current fluoroquinolone use was significantly associated with increased risk of aortic aneurysm and dissection. Health care providers need to be aware of this serious association and use fluoroquinolones judiciously in order to minimize the risk of the serious sequela of aortopathy.
Topics: Aortic Dissection; Anti-Bacterial Agents; Aortic Aneurysm; Bacterial Infections; Fluoroquinolones; Global Health; Humans; Incidence; Risk Assessment; Risk Factors
PubMed: 30309682
DOI: 10.1016/j.ijcard.2018.09.067 -
Surgical Endoscopy Feb 2014For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.
METHODS
A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.
RESULTS
This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3-90.6) for the ESD patients versus 98.7 % (95 % CI 97.4-99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4-78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9-90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4-11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2-13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3-5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0-6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9-13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8-3.7 %) for the TEM patients (P < 0.001).
CONCLUSIONS
The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.
Topics: Dissection; Humans; Intestinal Mucosa; Microsurgery; Neoplasm Recurrence, Local; Neoplasm Staging; Rectal Neoplasms; Rectum
PubMed: 24149849
DOI: 10.1007/s00464-013-3238-3 -
Cerebrovascular Diseases (Basel,... 2022Although the mechanism of stroke in cervical artery dissection (CAD) has been hypothesized to be embolization rather than hemodynamic compromise, there are a limited... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVE
Although the mechanism of stroke in cervical artery dissection (CAD) has been hypothesized to be embolization rather than hemodynamic compromise, there are a limited number of studies supporting this hypothesis. Detection of micro-embolic signals (MESs) using transcranial Doppler (TCD) helps in understanding the mechanism in these patients. A systematic review and meta-analysis were performed to estimate the prevalence of MES and its association with stroke outcomes in patients with acute stroke/TIA secondary to dissection.
METHODS
A comprehensive literature search was conducted for studies before January 26, 2021, in PubMed, Embase, Google Scholar, Cochrane Library, and ClinicalTrials.gov. Studies were identified that used TCD to detect MES in stroke/TIA patients secondary to CAD. Pooled prevalence was calculated. Entire statistical analysis was conducted in R version 3.6.2.
RESULTS
Eleven studies involving 112 patients (50 MES+, 62 MES-) were included in our meta-analysis. The pooled prevalence of MES among acute stroke/TIA patients secondary to dissection was 46.0% (95% CI 26.0-67.0%). The presence of MES was associated with an increased risk of early ischemic recurrence in patients with CAD. We could not estimate the functional outcome and mortality associated with the presence of MES due to the scarcity of data.
CONCLUSIONS
Our meta-analysis showed 46% prevalence of MES in the studies which looked at acute stroke/TIA secondary to CAD using TCD. This finding supports the assumption that embolism may be a major cause of stroke in patients with dissection although this could be determined only in a small population.
Topics: Embolism; Humans; Intracranial Embolism; Ischemic Attack, Transient; Stroke; Ultrasonography, Doppler, Transcranial
PubMed: 34753137
DOI: 10.1159/000519553 -
Techniques in Coloproctology Jan 2016Endoscopic submucosal dissection (ESD) and local excision (LE) are minimally invasive procedures that can be used to treat early rectal cancer. There are no current... (Comparative Study)
Comparative Study Meta-Analysis Review
Endoscopic submucosal dissection (ESD) and local excision (LE) are minimally invasive procedures that can be used to treat early rectal cancer. There are no current guidelines or consensus on the optimal treatment strategy for these lesions. A systematic review was conducted to compare the efficacy and safety of ESD and LE. A meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. To perform the statistical analysis, the odds ratio (OR) was used for categorical variables and the weighted mean difference (WMD) for continuous variables. Four studies, involving a total of 307 patients, were identified. The length of hospital stay was longer in the group of patients undergoing LE [weighted mean difference (WMD) -1.94; 95% CI -2.85 to -1.02; p < 0.0001]. The combined results of the individual studies showed no significant differences as regards en-bloc resection rate (OR 0.82; 95% CI 0.25-2.70; p = 0.74), R0 resection rate (OR 1.53; 95% CI 0.62-3.73; p = 0.35), overall complication rate (OR 0.67; 95% CI 0.26-1.69; p = 0.40), and tumor size (WMD 0.57; 95% CI -3.64 to 4.78; p = 0.79) between ESD and LE. When adopting the fixed effect model which takes into account the study size, ESD was associated with a lower recurrence rate than LE (OR 0.15; 95% CI 0.03-0.87; p = 0.03), while with the random-effect model the difference was not significant (OR 0.18; 95% CI 0.02-2.04; p = 0.17). Over the last decade improvements in technology have improved the technical feasibility of rectal ESD. In specialized centers with highly experienced endoscopists, ESD can provide high-quality en-bloc excision of rectal neoplasms equivalent to traditional local excision.
Topics: Aged; Colectomy; Dissection; Endoscopy, Gastrointestinal; Female; Humans; Intestinal Mucosa; Length of Stay; Male; Middle Aged; Neoplasm Recurrence, Local; Odds Ratio; Rectal Neoplasms; Rectum; Treatment Outcome
PubMed: 26519288
DOI: 10.1007/s10151-015-1383-5