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AJNR. American Journal of Neuroradiology Mar 2021Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the...
BACKGROUND AND PURPOSE
Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment.
MATERIALS AND METHODS
Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study.
RESULTS
The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4).
CONCLUSIONS
Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.
Topics: Adolescent; Adult; Aged; Catheters; Cerebral Angiography; Female; Humans; Male; Middle Aged; Observer Variation; Reproducibility of Results; Subarachnoid Hemorrhage; Vasospasm, Intracranial; Young Adult
PubMed: 33509923
DOI: 10.3174/ajnr.A7021 -
Plastic and Reconstructive Surgery Aug 2015Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of... (Review)
Review
BACKGROUND
Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of pharmacologic management vary, and may be shifting as a result of changes in the availability of individual medications. This review aims to provide a concise examination of the published literature regarding use, efficacy, and adverse effects of the agents described for local management of vascular spasm during microsurgery.
METHODS
A systematic review of the literature was performed to identify articles relevant to pharmacologic treatment of intraoperative vasospasm in vivo. An additional review of the literature was performed with regard to each agent identified in order to provide clinical background information.
RESULTS
Systematic review identified 20 articles, in which 14 vasodilator agents were evaluated. Drugs were classified into five pharmacologic categories: phosphodiesterase inhibitors (papaverine, pentoxifylline, and amrinone), local anesthetics (lidocaine), calcium channel blockers (nicardipine, verapamil, nifedipine, and magnesium sulfate), direct vasodilators (sodium nitroprusside, prostaglandin E1, nitroglycerin, and hydralazine), and alpha antagonists (phentolamine and chlorpromazine). Despite a variety of methods, these studies indicate some degree of experimental evidence of efficacy for each of these agents.
CONCLUSIONS
Available literature regarding use of topical vasodilating agents for intraoperative management of vasospasm during microsurgery is limited and largely based on animal models, which may not reliably generalize to the reconstructive patient population. Well-controlled translational study in clinically applicable and reproducible models is needed to guide evidence-based clinical management of this important phenomenon.
Topics: Administration, Topical; Constriction, Pathologic; Female; Follow-Up Studies; Hospital Mortality; Humans; Intraoperative Complications; Male; Microsurgery; Plastic Surgery Procedures; Risk Assessment; Survival Rate; Treatment Outcome; Vasoconstriction; Vasodilator Agents
PubMed: 25909299
DOI: 10.1097/PRS.0000000000001431 -
Stroke Jan 2010A recent meta-analysis investigating the efficacy of statin treatment in patients with aneurysmal subarachnoid hemorrhage reported a reduced incidence of vasospasm,... (Comparative Study)
Comparative Study Meta-Analysis Review
Effect of statin treatment on vasospasm, delayed cerebral ischemia, and functional outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis update.
BACKGROUND AND PURPOSE
A recent meta-analysis investigating the efficacy of statin treatment in patients with aneurysmal subarachnoid hemorrhage reported a reduced incidence of vasospasm, delayed cerebral ischemia, and mortality in statin-treated patients. However, the meta-analysis was criticized for its methodology, and several retrospective studies found no beneficial effect. We present the results of a new systematic review, which differs from the previous systematic review in its methodology, and by inclusion of the results of a fourth randomized, placebo-controlled trial. Summary of Review- All randomized, placebo-controlled trials investigating the effect of statins on vasospasm, delayed cerebral ischemia, and functional outcome in patients with aneurysmal subarachnoid hemorrhage were included. Outcomes were the number of patients with transcranial Doppler vasospasm, delayed cerebral ischemia, poor outcome, and mortality during follow-up. Effect sizes were expressed in (pooled) risk ratio estimates. Data were pooled using random-effects models.
RESULTS
In 4 studies, a total of 190 patients were included. No statistically significant effect was observed on transcranial Doppler vasospasm (pooled risk ratio, 0.99 [95% CI, 0.66 to 1.48]), delayed cerebral ischemia (pooled risk ratio, 0.57 [95% CI, 0.29 to 1.13]), poor outcome (pooled risk ratio, 0.92 [95% CI, 0.68 to 1.24]), or mortality (pooled risk ratio, 0.37 [95% CI, 0.13 to 1.10]).
CONCLUSIONS
The results of the present systematic review do not lend statistically significant support to the finding of a beneficial effect of statins in patients with aneurysmal subarachnoid hemorrhage as reported in a previous meta-analysis.
Topics: Brain Ischemia; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Randomized Controlled Trials as Topic; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 19875741
DOI: 10.1161/STROKEAHA.109.556332 -
Surgical Neurology International 2022The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural... (Review)
Review
BACKGROUND
The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural hematoma (SDH) of the infratentorial space without associated subarachnoid hemorrhage (SAH).
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature review was conducted in PubMed and Scopus electronic databases for relevant published cases of aneurysmal SDH (AnSDH) of the infratentorial compartment without associated SAH. The presentation, treatment, clinical course, and outcome of identified cases are compiled. In addition, a patient suffering from an infratentorial SDH following aneurysm rupture is presented with an illustrative case.
RESULTS
Three articles were identified and met inclusion criteria. All cases occurred from ruptured posterior communicating artery aneurysms. All patients arrived with a Hunt and Hess classification of 2 or less. Only one case was managed with operative aneurysm clipping and hematoma evacuation while the other three cases were managed endovascularly. There were no reported postoperative complications, vasospasm, or seizures reported. All patients had a final Modified Rankin score of 3 or less at last reported follow-up.
CONCLUSION
Infratentorial AnSDH without associated SAH is an etiology rarely reported in the literature. Here, we present a case report and systematic review demonstrating a relatively benign clinical course and outcome compared to report aneurysm rupture associated with SAH or mixed SAH and SDH. Moreover, there appear to be lower rates of vasospasm and improved outcomes in patients with isolated AnSDH compared to the literature aneurysmal SAH rates.
PubMed: 36447858
DOI: 10.25259/SNI_758_2022 -
BMJ Clinical Evidence Sep 2008Raynaud's phenomenon is episodic vasospasm of the peripheral vessels, causing pallor followed by cyanosis and redness with pain and sometimes paraesthesia, and, rarely,... (Review)
Review
INTRODUCTION
Raynaud's phenomenon is episodic vasospasm of the peripheral vessels, causing pallor followed by cyanosis and redness with pain and sometimes paraesthesia, and, rarely, ulceration of the fingers and toes. It presents as episodic colour changes of the digits, usually in response to cold exposure or stress. The classic triphasic colour change is white (ischaemia), then blue (deoxygenation), then red (reperfusion). Raynaud's phenomenon can be primary (idiopathic) or secondary to several different conditions and causes. This review deals with secondary Raynaud's phenomenon.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of self-help measures for secondary Raynaud's phenomenon? What are the effects of drug treatments for secondary Raynaud's phenomenon? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 25 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: alpha-blockers; angiotensin-converting enzyme (ACE) inhibitors; angiotensin II receptor antagonists; antithrombotics/inhibitors of platelet aggregation; biofeedback; calcium channel blockers; endothelin-1 receptor anatagonists; glyceryl trinitrate (transdermal); hand exercises; inositol nicotinate; moxisylyte; nafitidrofuryl oxylate; phosphodiesterase inhibitors; prostaglandins (oral, intravenous); relaxation therapy; serotonin reuptake inhibitors SRIs; smoking cessation; and warming hands and feet.
Topics: Administration, Oral; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Endothelin Receptor Antagonists; Humans; Phosphodiesterase Inhibitors; Raynaud Disease; Receptor, Endothelin A
PubMed: 19445801
DOI: No ID Found -
World Neurosurgery Jun 2021Cerebral vasospasm is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Many drugs have been tried to mitigate cerebral vasospasm and delayed... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Cerebral vasospasm is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). Many drugs have been tried to mitigate cerebral vasospasm and delayed cerebral ischemia. Cilostazol, a selective inhibitor of phosphodiesterase 3, is a promising agent in preventing cerebral vasospasm and delayed cerebral ischemia after aSAH. The objective of this article was to ascertain the effect of cilostazol on cerebral vasospasm after aSAH by performing meta-analysis and trial sequential analysis.
METHODS
A systematic search of the literature was performed, and all the eligible randomized controlled trials were included in the meta-analysis and trial sequential analysis.
RESULTS
A total of 454 articles were identified using the search criteria. Six articles were selected for systematic review and the 4 randomized controlled trials were included in the meta-analysis. The pooled odds ratio for symptomatic vasospasm, new-onset infarct, and angiographic vasospasm was 0.35 (95% confidence interval [CI], 0.21-0.59; P < 0.0001), 0.38 (95% CI, 0.21-0.66; P = 0.0007) and 0.49 (95% CI, 0.31-0.80; P = 0.004), respectively. The pooled risk ratio for unfavorable outcome was 0.52 (95% CI, 0.37-0.74; P = 0.0003).
CONCLUSIONS
Cilostazol decreases the prevalence of symptomatic vasospasm, new-onset infarct, and angiographic vasospasm when administered after aSAH. Trial sequential analysis increased the precision of our results because the defined thresholds of effect were met by the available studies. However, further studies involving patients from other geographic areas are required to confirm the generalization of the results.
Topics: Cilostazol; Humans; Phosphodiesterase 3 Inhibitors; Randomized Controlled Trials as Topic; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial
PubMed: 33631387
DOI: 10.1016/j.wneu.2021.02.069 -
Frontiers in Neurology 2024Cerebral vasospasm (CV) is a common complication of aneurysmal subarachnoid hemorrhage (aSAH), leading to increased morbidity and mortality rates. Endovascular therapy,...
BACKGROUND
Cerebral vasospasm (CV) is a common complication of aneurysmal subarachnoid hemorrhage (aSAH), leading to increased morbidity and mortality rates. Endovascular therapy, particularly intra-arterial vasodilator infusion (IAVI), has emerged as a potential alternative treatment for CV.
METHODS
A systematic review and meta-analysis were conducted to compare the efficacy of endovascular therapy with standard treatment in patients with CV following aSAH. The primary outcomes assessed were in-hospital mortality, discharge favorable outcome, and follow-up favorable outcome. Secondary outcomes included major infarction on CT, ICU stay duration, and total hospital stay.
RESULTS
Regarding our primary outcomes of interest, patients undergoing intervention exhibited a significantly lower in-hospital mortality compared to the standard treatment group, with the intervention group having only half the mortality risk (RR = 0.49, 95% CI [0.29, 0.83], = 0.008). However, there were no significant differences between the two groups in terms of discharge favorable outcome (RR = 0.99, 95% CI [0.68, 1.45], = 0.963) and follow-up favorable outcome (RR = 1.09, 95% CI [0.86, 1.39], = 0.485). Additionally, there was no significant difference in major infarction rates (RR = 0.79, 95% CI [0.34, 1.84], = 0.588). It is important to note that patients undergoing endovascular treatment experienced longer stays in the ICU (MD = 6.07, 95% CI [1.03, 11.12], = 0.018) and extended hospitalization (MD = 5.6, 95% CI [3.63, 7.56], < 0.001). Subgroup analyses based on the mode of endovascular treatment further supported the benefits of IAVI in lowering in-hospital mortality (RR = 0.5, 95% CI [0.27, 0.91], = 0.023).
CONCLUSION
Endovascular therapy, particularly IAVI, holds promising potential in reducing in-hospital mortality for patients with CV following aSAH. However, it did not show significant improvement in long-term prognosis and functional recovery. Further research with larger sample sizes and randomized controlled trials is necessary to validate these findings and optimize the treatment strategy for cerebral vasospasm in aSAH patients.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42023451741.
PubMed: 38715691
DOI: 10.3389/fneur.2024.1360511 -
BMJ Clinical Evidence Dec 2008Raynaud's phenomenon is an episodic vasospasm of the peripheral arteries, causing pallor followed by cyanosis and redness with pain and sometimes paraesthesia. On rare... (Review)
Review
INTRODUCTION
Raynaud's phenomenon is an episodic vasospasm of the peripheral arteries, causing pallor followed by cyanosis and redness with pain and sometimes paraesthesia. On rare occasions it can lead to ulceration of the fingers and toes (and in some cases of the ears or nose). This review focuses on primary (idiopathic) Raynaud's phenomenon occurring in the absence of an underlying disease. The prevalence of primary Raynaud's phenomenon varies by sex, country, and exposure to workplace vibration.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for primary Raynaud's phenomenon? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: amlodipine, diltiazem, exercise, inositol nicotinate, keeping warm, moxisylyte (thymoxamine), naftidrofuryl oxalate, nicardipine, nifedipine, prazosin, and smoking cessation.
Topics: Administration, Oral; Humans; Nifedipine; Prevalence; Raynaud Disease; Ulcer; Vibration
PubMed: 19445785
DOI: No ID Found -
Neurosurgery Dec 2023Clazosentan has been studied to treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH).This meta-analysis of randomized controlled trials updates the... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Clazosentan has been studied to treat cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH).This meta-analysis of randomized controlled trials updates the current knowledge regarding the efficacy and safety of clazosentan compared with placebo after aSAH.
METHODS
Databases were systematically searched for randomized controlled trials directly comparing the use of clazosentan and placebo for the treatment of cerebral vasospasm after aSAH. Additional eligibility criteria were the report of any of the outcomes of interest (vasospasm, morbidity, functional outcome, or mortality). The primary outcome was vasospasm-related delayed cerebral ischemia (DCI). The analyses were stratified by clazosentan dosage (low or high dose) and aneurysm treatment modality (clipping or coiling). The Cochrane RoB-2 tool was used for studies quality assessment.
RESULTS
Six studies comprising 7 clinical trials were included, involving 2778 patients. Clazosentan decreased the risk of vasospasm-related DCI (risk ratio [RR] 0.56, 95% CI 0.38-0.81) and delayed ischemic neurological deficit (RR 0.63, 95% 0.50-0.80). Angiographic vasospasm (RR 0.54, 95% CI 0.47-0.61) was also decreased. Functional outcomes (favorable Glasgow Outcome Scale, RR 0.99, 95% CI 0.79-1.24) and death (RR 1.03, 95% CI 0.71-1.49) did not change. Meanwhile, adverse events were increased by clazosentan (RR 1.54, 95% CI 1.35-1.76).
CONCLUSION
Clazosentan decreased vasospasm-related DCI and angiographic vasospasm but did not improve functional outcomes or mortality. Adverse events were increased by clazosentan.
Topics: Humans; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial; Dioxanes; Brain Ischemia; Cerebral Infarction
PubMed: 37462365
DOI: 10.1227/neu.0000000000002601 -
British Journal of Anaesthesia Jul 2016: The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of... (Review)
Review
UNLABELLED
: The leading cause of morbidity and mortality after surviving the rupture of an intracranial aneurysm is delayed cerebral ischaemia (DCI). We present an update of recent literature on the current status of prevention and treatment strategies for DCI after aneurysmal subarachnoid haemorrhage. A systematic literature search of three databases (PubMed, ISI Web of Science, and Embase) was performed. Human clinical trials assessing treatment strategies, published in the last 5 yr, were included based on full-text analysis. Study data were extracted using tables depicting study type, sample size, and outcome variables. We identified 49 studies meeting our inclusion criteria. Clazosentan, magnesium, and simvastatin have been tested in large high-quality trials but failed to show a beneficial effect. Cilostazol, eicosapentaenoic acid, erythropoietin, heparin, and methylprednisolone yield promising results in smaller, non-randomized or retrospective studies and warrant further investigation. Topical application of nicardipine via implants after clipping has been shown to reduce clinical and angiographic vasospasm. Methods to improve subarachnoid blood clearance have been established, but their effect on outcome remains unclear. Haemodynamic management of DCI is evolving towards euvolaemic hypertension. Endovascular rescue therapies, such as percutaneous transluminal balloon angioplasty and intra-arterial spasmolysis, are able to resolve angiographic vasospasm, but their effect on outcome needs to be proved. Many novel therapies for preventing and treating DCI after aneurysmal subarachnoid haemorrhage have been assessed, with variable results. Limitations of the study designs often preclude definite statements. Current evidence does not support prophylactic use of clazosentan, magnesium, or simvastatin. Many strategies remain to be tested in larger randomized controlled trials.
CLINICAL TRIAL REGISTRATION
This systematic review was registered in the international prospective register of systematic reviews.
PROSPERO
CRD42015019817.
Topics: Angioplasty; Brain Ischemia; Humans; Neuroprotective Agents; Subarachnoid Hemorrhage
PubMed: 27160932
DOI: 10.1093/bja/aew095