Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: a pooled data meta-analysis.
Bakker Nicolaas A,Groen Rob J M,Foumani Mahrouz,Uyttenboogaart Maarten,Eshghi Omid S,Metzemaekers Jan D M,Lammers Natasja,Luijckx Gert-Jan,Van Dijk J Marc C
Journal of neurosurgery
OBJECT:A repeat digital subtraction angiography (DSA) study of the cranial vasculature is routinely performed in patients with diffuse nonperimesencephalic subarachnoid hemorrhage (SAH) after negative baseline CT angiography (CTA) and DSA studies. However, DSA carries a low but substantial risk of neurological complications. Therefore, the authors evaluated the added value of repeat DSA in patients with initial angiographically negative diffuse nonperimesencephalic SAH. METHODS:A systematic review of the contemporary literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies from January 2000 onward were reviewed since imaging modalities have much improved over the last decade. A pooled analysis was conducted to identify the detection rate of repeat DSA. In addition, the diagnostic yield of repeat DSAs in a prospectively maintained single-center series of 1051 consecutive patients with SAH was added to the analysis. RESULTS:An initial search of the literature yielded 179 studies, 8 of which met the selection criteria. Another 45 patients from the authors' institution were included in the study, providing 368 patients eligible for the pooled analysis. In 37 patients (10.0%, 95% CI 7.4%-13.6%) an aneurysm was detected on repeat DSA. The timing of the repeat DSA varied from 1 to 6 weeks after the initial DSA. The use of 3D techniques was poorly described among these studies, and no direct comparisons between CTA and DSA were made. CONCLUSIONS:Repeat DSA is still warranted in patients with a diffuse nonperimesencephalic SAH and negative initial assessment. However, the exact timing of the repeat DSA is subject to debate.
10.3171/2013.9.JNS131337
Neuroimaging characteristics of ruptured aneurysm as predictors of outcome after aneurysmal subarachnoid hemorrhage: pooled analyses of the SAHIT cohort.
Jaja Blessing N R,Lingsma Hester,Steyerberg Ewout W,Schweizer Tom A,Thorpe Kevin E,Macdonald R Loch,
Journal of neurosurgery
OBJECT Neuroimaging characteristics of ruptured aneurysms are important to guide treatment selection, and they have been studied for their value as outcome predictors following aneurysmal subarachnoid hemorrhage (SAH). Despite multiple studies, the prognostic value of aneurysm diameter, location, and extravasated SAH clot on computed tomography scan remains debatable. The authors aimed to more precisely ascertain the relation of these factors to outcome. METHODS The data sets of studies included in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository were analyzed including data on ruptured aneurysm location and diameter (7 studies, n = 9125) and on subarachnoid clot graded on the Fisher scale (8 studies; n = 9452) for the relation to outcome on the Glasgow Outcome Scale (GOS) at 3 months. Prognostic strength was quantified by fitting proportional odds logistic regression models. Univariable odds ratios (ORs) were pooled across studies using random effects models. Multivariable analyses were adjusted for fixed effect of study, age, neurological status on admission, other neuroimaging factors, and treatment modality. The neuroimaging predictors were assessed for their added incremental predictive value measured as partial R(2). RESULTS Spline plots indicated outcomes were worse at extremes of aneurysm size, i.e., less than 4 or greater than 9 mm. In between, aneurysm size had no effect on outcome (OR 1.03, 95% CI 0.98-1.09 for 9 mm vs 4 mm, i.e., 75th vs 25th percentile), except in those who were treated conservatively (OR 1.17, 95% CI 1.02-1.35). Compared with anterior cerebral artery aneurysms, posterior circulation aneurysms tended to result in slightly poorer outcome in patients who underwent endovascular coil embolization (OR 1.13, 95% CI 0.82-1.57) or surgical clipping (OR 1.32, 95% CI 1.10-1.57); the relation was statistically significant only in the latter. Fisher CT subarachnoid clot burden was related to outcome in a gradient manner. Each of the studied predictors accounted for less than 1% of the explained variance in outcome. CONCLUSIONS This study, which is based on the largest cohort of patients so far analyzed, has more precisely determined the prognostic value of the studied neuroimaging factors. Treatment choice has strong influence on the prognostic effect of aneurysm size and location. These findings should guide the development of reliable prognostic models and inform the design and analysis of future prospective studies, including clinical trials.
10.3171/2015.4.JNS142753
Carotid plaque hemorrhage on magnetic resonance imaging strongly predicts recurrent ischemia and stroke.
Hosseini Akram A,Kandiyil Neghal,Macsweeney Shane T S,Altaf Nishath,Auer Dorothee P
Annals of neurology
OBJECTIVE:There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis. METHODS:One hundred seventy-nine symptomatic patients with ≥ 50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan-Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events. RESULTS:One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8-30.1, p < 0.001) and stroke alone (HR = 35.0, 95% CI = 4.7-261.6, p = 0.001). Meta-analysis of published data confirmed this association between MRIPH and recurrent cerebral ischemic events in symptomatic carotid artery stenosis (odds ratio = 12.2, 95% CI = 5.5-27.1, p < 0.00001). INTERPRETATION:MRIPH independently and strongly predicts recurrent ipsilateral ischemic events, and stroke alone, in symptomatic ≥ 50% carotid artery stenosis. The very low stroke risk in patients without MRIPH puts into question current risk-benefit assessment for CEA in this subgroup.
10.1002/ana.23876
Hematoma Heterogeneity on Noncontrast Computed Tomography Predicts Intracerebral Hematoma Expansion: A Meta-Analysis.
Zhang Danfeng,Chen Jigang,Guo Jiaming,Jiang Ying,Dong Yan,Ping-Chi Chen Benjamin,Wang Junyu,Hou Lijun
World neurosurgery
BACKGROUND:Hematoma expansion (HE) is independently associated with clinical outcome after intracerebral hemorrhage (ICH). Hematoma heterogeneity on noncontrast computed tomography (NCCT) is reportedly predictive of HE, but conclusions are inconsistent. We sought to clarify the relationship between hematoma heterogeneity and HE by pooling the pertinent publications. METHODS:The Cochrane Library, PubMed, and Embase were searched for related studies examining the correlation of HE with hematoma heterogeneity, and the secondary endpoint was defined as poor outcome. The effect size was odds ratio (OR) with its 95% confidence interval (CI). Results from each study were pooled using a random-effects model. RESULTS:Ten studies were included with a total of 5931 patients and 675 HEs. We detected a statistically significant association between NCCT heterogeneity and HE (OR, 2.55; 95% CI, 1.82-3.56; P < 0.001), while the correlation with poor outcome was nonsignificant (OR, 1.20; 95% CI, 0.94-1.54, P = 0.15). CONCLUSIONS:Our findings indicate that hematoma heterogeneity on NCCT is positively associated with an increased risk of HE. The relationship between hematoma heterogeneity and poor outcome merits evaluation in further prospective studies.
10.1016/j.wneu.2018.03.048
Predictors of Outcome With Cerebral Autoregulation Monitoring: A Systematic Review and Meta-Analysis.
Rivera-Lara Lucia,Zorrilla-Vaca Andres,Geocadin Romer,Ziai Wendy,Healy Ryan,Thompson Richard,Smielewski Peter,Czosnyka Marek,Hogue Charles W
Critical care medicine
OBJECTIVE:To compare cerebral autoregulation indices as predictors of patient outcome and their dependence on duration of monitoring. DATA SOURCES:Systematic literature search and meta-analysis using PubMed, EMBASE, and the Cochrane Library from January 1990 to October 2015. STUDY SELECTION:We chose articles that assessed the association between cerebral autoregulation indices and dichotomized or continuous outcomes reported as standardized mean differences or correlation coefficients (R), respectively. Animal and validation studies were excluded. DATA EXTRACTION:Two authors collected and assessed the data independently. The studies were grouped into two sets according to the type of analysis used to assess the relationship between cerebral autoregulation indices and predictors of outcome (standardized mean differences or R). DATA SYNTHESIS:Thirty-three studies compared cerebral autoregulation indices and patient outcomes using standardized mean differences, and 20 used Rs. The only data available for meta-analysis were from patients with traumatic brain injury or subarachnoid hemorrhage. Based on z score analysis, the best three cerebral autoregulation index predictors of mortality or Glasgow Outcome Scale for patients with traumatic brain injury were the pressure reactivity index, transcranial Doppler-derived mean velocity index based on cerebral perfusion pressure, and autoregulation reactivity index (z scores: 8.97, 6.01, 3.94, respectively). Mean velocity index based on arterial blood pressure did not reach statistical significance for predicting outcome measured as a continuous variable (p = 0.07) for patients with traumatic brain injury. For patients with subarachnoid hemorrhage, autoregulation reactivity index was the only cerebral autoregulation index that predicted patient outcome measured with the Glasgow Outcome Scale as a continuous outcome (R = 0.82; p = 0.001; z score, 3.39). We found a significant correlation between the duration of monitoring and predictive value for mortality (R = 0.78; p < 0.001). CONCLUSIONS:Three cerebral autoregulation indices, pressure reactivity index, mean velocity index based on cerebral perfusion pressure, and autoregulation reactivity index were the best outcome predictors for patients with traumatic brain injury. For patients with subarachnoid hemorrhage, autoregulation reactivity index was the only cerebral autoregulation index predictor of Glasgow Outcome Scale. Continuous assessment of cerebral autoregulation predicted outcome better than intermittent monitoring.
10.1097/CCM.0000000000002251
Accuracy of spot sign in predicting hematoma expansion and clinical outcome: A meta-analysis.
Medicine
BACKGROUND:Spot sign on computed tomography angiography (CTA) has been reported as a risk factor for hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). We performed a meta-analysis to investigate the predictive accuracy of spot sign for HE, mortality risk, and poor outcome. METHODS:We searched PubMed, Embase, and the Cochrane Library for relevant studies. Studies were incorporated if they reported data on relationship between CTA spot sign and HE, mortality or poor outcome. RESULTS:Twenty-nine studies were pooled in this meta-analysis. The spot sign occurred in 23.4% patients with spontaneous ICH undergoing CTA scans. It showed a sensitivity of 62% (95% confidence interval [CI] 54-69), with a specificity of 88% (95% CI 85-91). Spot sign was related with increased risk of HE (odds ratios [OR] 8.49, 95% CI 7.28-9.90). In the analysis of association between spot sign and outcome, patients with spot sign had a significant higher risk of in-hospital death (OR 5.08, 95% CI 3.16-8.18) and 3-month death (OR 3.80, 95% CI 2.62-5.52). The spot sign was also a predictor of poor outcome at discharge (OR 6.40, 95% CI 3.41-12.03) and at 3 months (OR 4.44, 95% CI 2.33-8.46). CONCLUSIONS:The overall incidence of CTA spot sign in spontaneous ICH patients is substantial. Spot sign demonstrated a good diagnostic performance in predicting HE and was closely associated with increased risk of death and poor outcome.
10.1097/MD.0000000000011945
The accuracy of spot sign in predicting hematoma expansion after intracerebral hemorrhage: a systematic review and meta-analysis.
Du Fei-Zhou,Jiang Rui,Gu Ming,He Ci,Guan Jing
PloS one
PURPOSE:The role of spot sign on computed tomography angiography (CTA) for predicting hematoma expansion (HE) after primary intracerebral hemorrhage (ICH) has been the focus of many studies. Our study sought to evaluate the predictive accuracy of spot signs for HE in a meta-analytic approach. MATERIALS AND METHODS:The database of Pubmed, Embase, and the Cochrane Library were searched for eligible studies. Researches were included if they reported data on HE in primary ICH patients, assessed by spot sign on first-pass CTA. Studies with additional data of second-pass CTA, post-contrast CT (PCCT) and CT perfusion (CTP) were also included. RESULTS:18 studies were pooled into the meta-analysis, including 14 studies of first-pass CTA, and 7 studies of combined CT modalities. In evaluating the accuracy of spot sign for predicting HE, studies of first-pass CTA showed that the sensitivity was 53% (95% CI, 49%-57%) with a specificity of 88% (95% CI, 86%-89%). The pooled positive likelihood ratio (PLR) was 4.70 (95% CI, 3.28-6.74) and the negative likelihood ratio (NLR) was 0.44 (95% CI, 0.34-0.58). For studies of combined CT modalities, the sensitivity was 73% (95% CI, 67%-79%) with a specificity of 88% (95% CI, 86%-90%). The aggregated PLR was 6.76 (95% CI, 3.70-12.34) and the overall NLR was 0.17 (95% CI 0.06-0.48). CONCLUSIONS:Spot signs appeared to be a reliable imaging biomarker for HE. The additional detection of delayed spot sign was helpful in improving the predictive accuracy of early spot signs. Awareness of our results may impact the primary ICH care by providing supportive evidence for the use of combined CT modalities in detecting spot signs.
10.1371/journal.pone.0115777
Clinical Significance of Magnetic Resonance Imaging Markers of Vascular Brain Injury: A Systematic Review and Meta-analysis.
Debette Stéphanie,Schilling Sabrina,Duperron Marie-Gabrielle,Larsson Susanna C,Markus Hugh S
JAMA neurology
Importance:Covert vascular brain injury (VBI) is highly prevalent in community-dwelling older persons, but its clinical and therapeutic implications are debated. Objective:To better understand the clinical significance of VBI to optimize prevention strategies for the most common age-related neurological diseases, stroke and dementia. Data Source:We searched for articles in PubMed between 1966 and December 22, 2017, studying the association of 4 magnetic resonance imaging (MRI) markers of covert VBI (white matter hyperintensities [WMHs] of presumed vascular origin, MRI-defined covert brain infarcts [BIs], cerebral microbleeds [CMBs], and perivascular spaces [PVSs]) with incident stroke, dementia, or death. Study Selection:Data were taken from prospective, longitudinal cohort studies including 50 or more adults. Data Extraction and Synthesis:We performed inverse variance-weighted meta-analyses with random effects and z score-based meta-analyses for WMH burden. The significance threshold was P < .003 (17 independent tests). We complied with the Meta-analyses of Observational Studies in Epidemiology guidelines. Main Outcomes and Measures:Stroke (hemorrhagic and ischemic), dementia (all and Alzheimer disease), and death. Results:Of 2846 articles identified, 94 studies were eligible, with up to 14 529 participants for WMH, 16 012 participants for BI, 15 693 participants for CMB, and 4587 participants for PVS. Extensive WMH burden was associated with higher risk of incident stroke (hazard ratio [HR], 2.45; 95% CI, 1.93-3.12; P < .001), ischemic stroke (HR, 2.39; 95% CI, 1.65-3.47; P < .001), intracerebral hemorrhage (HR, 3.17; 95% CI, 1.54-6.52; P = .002), dementia (HR, 1.84; 95% CI, 1.40-2.43; P < .001), Alzheimer disease (HR, 1.50; 95% CI, 1.22-1.84; P < .001), and death (HR, 2.00; 95% CI, 1.69-2.36; P < .001). Presence of MRI-defined BIs was associated with higher risk of incident stroke (HR, 2.38; 95% CI, 1.87-3.04; P < .001), ischemic stroke (HR, 2.18; 95% CI, 1.67-2.85; P < .001), intracerebral hemorrhage (HR, 3.81; 95% CI, 1.75-8.27; P < .001), and death (HR, 1.64; 95% CI, 1.40-1.91; P < .001). Presence of CMBs was associated with increased risk of stroke (HR, 1.98; 95% CI, 1.55-2.53; P < .001), ischemic stroke (HR, 1.92; 95% CI, 1.40-2.63; P < .001), intracerebral hemorrhage (HR, 3.82; 95% CI, 2.15-6.80; P < .001), and death (HR, 1.53; 95% CI, 1.31-1.80; P < .001). Data on PVS were limited and insufficient to conduct meta-analyses but suggested an association of high PVS burden with increased risk of stroke, dementia, and death; this requires confirmation. Conclusions and Relevance:We report evidence that MRI markers of VBI have major clinical significance. This research prompts careful evaluation of the benefit-risk ratio for available prevention strategies in individuals with covert VBI.
10.1001/jamaneurol.2018.3122
Radiological scales predicting delayed cerebral ischemia in subarachnoid hemorrhage: systematic review and meta-analysis.
van der Steen Wessel E,Leemans Eva L,van den Berg René,Roos Yvo B W E M,Marquering Henk A,Verbaan Dagmar,Majoie Charles B L M
Neuroradiology
PURPOSE:Delayed cerebral ischemia (DCI) is a severe complication of aneurysmal subarachnoid hemorrhage (aSAH). The extent of subarachnoid blood is a strong predictor of DCI and is frequently estimated with the Fisher scale, modified Fisher scale, or Hijdra sum score. It is unclear which scale has the strongest association with clinical DCI. To evaluate this, we performed a systematic review of the literature. METHODS:We performed a MEDLINE and EMBASE search from 1980 to 20th of June 2017. Radiological grade and occurrence of clinical DCI were extracted along with odds ratios (ORs) for DCI. When possible, pooled ORs with 95% confidence intervals were calculated per grade increase on the radiological scale. RESULTS:Fifty-three studies were included. The Fisher scale was significantly associated with DCI in 62% of the studies compared to 88-100% for the other scales. In studies using the Fisher scale, Fisher 3 had the strongest association with DCI (pooled OR 3.21 (1.87-5.49)). In studies using the modified Fisher score, DCI occurred most frequently (42%) in modified Fisher 4. No pooled OR could be calculated for the other scales. CONCLUSION:The Fisher scale, modified Fisher scale, and Hijdra sum score are all associated with clinical DCI. The risk of DCI, however, does not increase with increasing Fisher grade as opposed to the modified Fisher scale. Furthermore, the modified Fisher scale was more commonly significantly associated with DCI than the Fisher scale, which may advocate using the modified Fisher in future SAH-related studies.
10.1007/s00234-019-02161-9
Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time.
Dowlatshahi Dar,Brouwers H Bart,Demchuk Andrew M,Hill Michael D,Aviv Richard I,Ufholz Lee-Anne,Reaume Michael,Wintermark Max,Hemphill J Claude,Murai Yasuo,Wang Yongjun,Zhao Xingquan,Wang Yilong,Li Na,Sorimachi Takatoshi,Matsumae Mitsunori,Steiner Thorsten,Rizos Timolaos,Greenberg Steven M,Romero Javier M,Rosand Jonathan,Goldstein Joshua N,Sharma Mukul
Stroke
BACKGROUND AND PURPOSE:Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. METHODS:We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. RESULTS:Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%. CONCLUSIONS:The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.
10.1161/STROKEAHA.115.012012
Prediction of upper extremity motor recovery after subacute intracerebral hemorrhage through diffusion tensor imaging: a systematic review and meta-analysis.
Kumar Pradeep,Yadav Arun Kumar,Misra Shubham,Kumar Amit,Chakravarty Kamalesh,Prasad Kameshwar
Neuroradiology
INTRODUCTION:Early assessment of the pyramidal tracts is important for intracerebral hemorrhage (ICH) patients in order to decide the optimal treatment or to assess appropriate rehabilitation strategies, and management of patient expectations and goals. The purpose of this study was to systematically review and summarize the current available literature on the value of Fractional Anisotropy (FA) parameter of the diffusion tensor imaging (DTI) in predicting upper extremity (UE) motor recovery after subacute ICH. METHODS:PubMed, EMBASE, MEDLINE, Google Scholar, and Cochrane CENTRAL searches were conducted from 1 January 1950 to 31 March 2016 which were supplemented with relevant articles identified in the references. Pooled estimate using correlation between DTI parameter FA and UE motor recovery was done using comprehensive meta-analysis software. RESULTS:Out of 97 citations, only eight studies met the criteria for inclusion in the systematic review and six studies were included in the meta-analysis. A random effects model revealed that DTI parameter FA is a significant predictor for UE motor recovery after subacute ICH (correlation coefficient = 0.56; 95 % confidence interval 0.44 to 0.65, P value <0.001). However, moderate heterogeneity was observed between the studies (Tau-squared = 0.28, I-squared = 70.3). CONCLUSION:The studies reported so far on correlation between FA parameter of DTI and UE motor recovery in ICH patients are few with small sample sizes. This meta-analysis suggests a strong correlation between DTI parameter FA and UE motor recovery in ICH patients. Further well-designed prospective studies embedded with larger sample size are needed to confirm these findings.
10.1007/s00234-016-1718-6
Prognostic significance of leukoaraiosis in intracerebral hemorrhage: A meta-analysis.
Yu Zhiyuan,Zheng Jun,Guo Rui,Ma Lu,You Chao,Li Hao
Journal of the neurological sciences
BACKGROUND:Patients with intracerebral hemorrhage (ICH) have high disability and mortality. Leukoaraiosis refers to the diffuse abnormalities of white matter on neuroimaging, which has been suggested to be with poor outcome in patients with ICH. This meta-analysis was performed to summarize the current evidence on the prognostic significance of leukoaraiosis in ICH patients. METHODS:Databases were searched for published studies about leukoaraiosis and prognosis in patients with ICH. Data from eligible studies were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) from each study were combined with DerSimonian-Laird method and random effect model for quantitative analysis. Begg's funnel plot was adopted to assess the publication bias. RESULTS:A total of nine studies with 4948 patients were finally included in this meta-analysis. Six studies reported functional outcome, two studies reported mortality, and another study reported both functional outcome and mortality. The meta-analysis showed that leukoaraiosis was significantly associated with worse functional outcome in patients with ICH (OR = 1.40, 95%CI 1.17-1.68, P < .001). In addition, leukoaraiosis was also significantly associated with higher mortality in patients with ICH (OR = 1.59, 95%CI 1.21-2.08, P = .001). CONCLUSIONS:Leukoaraiosis is significantly associated with both worse functional outcome and higher mortality in patients with ICH. Leukoaraiosis can be a useful imaging marker for predicting outcome in patients with ICH.
10.1016/j.jns.2018.12.022
Predictive Validity of Hypodensities on Noncontrast Computed Tomography for Hematoma Growth in Intracerebral Hemorrhage: a Meta-Analysis.
Yu Zhiyuan,Zheng Jun,Ma Lu,Guo Rui,You Chao,Li Hao
World neurosurgery
OBJECTIVE:Intracerebral hemorrhage (ICH) is a type of stroke that leads to high mortality. Hematoma growth (HG) happens in about one third of all patients with ICH and is independently related to poor outcome. Previous studies have shown that an indicator on noncontrast computed tomography, called hypodensities, can predict HG in patients with ICH. Thus, this study was done to assess the predictive validity of this marker. METHODS:Bibliographic databases were searched, without language restriction, for original investigation on hypodensities and HG in ICH. Data were extracted, and study quality was assessed by 2 reviewers independently. Pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio, and their 95% confidence intervals (CIs) were obtained. A summary receiver operating characteristic curve was depicted. RESULTS:Five cohorts with 2157 patients in 4 studies were included in the present meta-analysis. The pooled sensitivity was 0.58 (95% CI 0.46-0.68) and the pooled specificity was 0.71 (95% CI 0.62-0.79). In addition, the pooled positive LR was 2.0 (95% CI 1.6-2.5) and the pooled negative LR was 0.60 (95% CI 0.49-0.73). The pooled diagnostic odds ratio was 3 (95% CI 2-5) and the area under summary receiver operating characteristic curve was 0.69 (95% CI 0.65-0.73). CONCLUSIONS:This study suggests that hypodensities on noncontrast computed tomography can be helpful in HG prediction, although its pooled predictive values are not very satisfying in the current study. The role of hypodensities in predicting HG should be confirmed by further studies.
10.1016/j.wneu.2018.11.239
Cerebral autoregulation in hemorrhagic stroke: A systematic review and meta-analysis of transcranial Doppler ultrasonography studies.
Minhas Jatinder S,Panerai Ronney B,Ghaly George,Divall Pip,Robinson Thompson G
Journal of clinical ultrasound : JCU
PURPOSE:International guidelines advocate intensive blood pressure (BP) lowering within 6 hours of acute intracerebral hemorrhage (ICH) to a target systolic BP of 130-140 mm Hg, though more intensive lowering may be associated with adverse outcome. Observational studies suggest impaired cerebral autoregulation (CA) following ICH. Transcranial Doppler ultrasonography (TCD), alongside continuous BP monitoring, provides a noninvasive bedside investigation that offers detailed perspectives on physiological perturbations post-acute ICH. This systematic review and meta-analysis focuses on all TCD studies of CA in ICH. METHODS:MEDLINE, EMBASE, and CENTRAL were searched for studies of hemorrhagic stroke and blood flow measurement. RESULTS:Eight studies met inclusion criteria (293 ICH patients); CA was impaired up to 12-days post-acute ICH. Impaired CA was evidenced by reduced transfer function analysis phase and higher mean flow correlation values: these were associated with worsened clinical parameters including ICH-volume and Glasgow Coma Scale. Meta-analysis of CBV demonstrated that, compared to controls, mean CBV was significantly lower in the ipsilateral (49.7 vs 64.8 cm s , Z = 4.26, P < .0001) and contralateral hemispheres following ICH (51.5 vs 64.8 cm s , Z = 3.44, P = .0006). CONCLUSION:Lower mean CBV in combination with impaired CA may have implications for more intensive BP lowering and warrants further studies examining such strategies on cerebral blood flow and its regulatory mechanisms.
10.1002/jcu.22645
Cortical superficial siderosis and recurrent intracerebral hemorrhage risk in cerebral amyloid angiopathy: Large prospective cohort and preliminary meta-analysis.
Charidimou Andreas,Boulouis Gregoire,Roongpiboonsopit Duangnapa,Xiong Li,Pasi Marco,Schwab Kristin M,Rosand Jonathan,Gurol M Edip,Greenberg Steven M,Viswanathan Anand
International journal of stroke : official journal of the International Stroke Society
BACKGROUND:We aimed to investigate cortical superficial siderosis as an MRI predictor of lobar intracerebral hemorrhage (ICH) recurrence risk in cerebral amyloid angiopathy (CAA), in a large prospective MRI cohort and a systematic review. METHODS:We analyzed a single-center MRI prospective cohort of consecutive CAA-related ICH survivors. Using Kaplan-Meier and Cox regression analyses, we investigated cortical superficial siderosis and ICH risk, adjusting for known confounders. We pooled data with eligible published cohorts in a two-stage meta-analysis using random effects models. Covariate-adjusted hazard rations (adj-HR) from pre-specified multivariable Cox proportional hazard models were used. RESULTS:The cohort included 240 CAA-ICH survivors (cortical superficial siderosis prevalence: 36%). During a median follow-up of 2.6 years (IQR: 0.9-5.1 years) recurrent ICH occurred in 58 patients (24%). In prespecified multivariable Cox regression models, cortical superficial siderosis presence and disseminated cortical superficial siderosis were independent predictors of increased symptomatic ICH risk at follow-up (HR: 2.26; 95% CI: 1.31-3.87, p = 0.003 and HR: 3.59; 95% CI: 1.96-6.57, p < 0.0001, respectively). Three cohorts including 443 CAA-ICH patients in total were eligible for meta-analysis. During a mean follow-up of 2.5 years (range: 2-3 years) 92 patients experienced recurrent ICH (pooled risk ratio: 6.9% per year, 95% CI: 4.2%-9.7% per year). In adjusted pooled analysis, any cortical superficial siderosis and disseminated cortical superficial siderosis were the only independent predictors associated with increased lobar ICH recurrence risk (adj-HR: 2.4; 95% CI: 1.5-3.7; p < 0.0001, and adj-HR: 4.4; 95% CI: 2-9.9; p < 0.0001, respectively). CONCLUSIONS:In CAA-ICH patients, cortical superficial siderosis presence and extent are the most important MRI prognostic risk factors for lobar ICH recurrence. These results can help guide clinical decision making in patients with CAA.
10.1177/1747493019830065
The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis.
Baldon Isabella Vargas,Amorim Andre Candeas,Santana Larissa Marques,Solla Davi J,Kolias Angelos,Hutchinson Peter,Paiva Wellingson S,Rosa-Júnior Marcos
PloS one
BACKGROUND:The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI). PURPOSE:To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality. DATA SOURCES:The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies. STUDY SELECTION:A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria. DATA ANALYSIS:All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74-10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24-4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03-7.47, p = 0.04). DATA SYNTHESIS:This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality. LIMITATIONS:Only four articles were selected. CONCLUSIONS:The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.
10.1371/journal.pone.0235561
Leukoaraiosis, Cerebral Hemorrhage, and Outcome After Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis (v1).
Charidimou Andreas,Pasi Marco,Fiorelli Marco,Shams Sara,von Kummer Rüdiger,Pantoni Leonardo,Rost Natalia
Stroke
BACKGROUND AND PURPOSE:We performed a meta-analysis to assess whether leukoaraiosis on brain computed tomographic scans of acute ischemic stroke patients treated with intravenous thrombolysis is associated with an increased risk of symptomatic intracerebral hemorrhage (sICH) or poor functional outcome at 3 to 6 months after stroke, or both. METHODS:We searched PubMed and pooled relevant data in meta-analyses using random effects models. Using odds ratios (OR), we quantified the strength of association between the presence and severity of leukoaraiosis and post-thrombolysis sICH or 3- to 6-month modified Rankin Score >2. RESULTS:Eleven eligible studies (n=7194) were pooled in meta-analysis. The risk of sICH was higher in patients with leukoaraiosis (OR, 1.55; 95% confidence interval [CI], 1.17-2.06; P=0.002) and severe leukoaraiosis (OR, 2.53; 95% CI, 1.92-3.34; P<0.0001) compared with patients without leukoaraiosis. Leukoaraiosis was an independent predictor of sICH in 6 included studies (n=4976; adjusted OR, 1.75; 95% CI, 1.35-2.27; P<0.0001). OR for leukoaraiosis and poor 3- to 6-month outcome was 2.02 (95% CI, 1.54-2.65; P<0.0001), with significant statistical heterogeneity (I(2), 75.7%; P=0.002). In adjusted analyses, leukoaraiosis was an independent predictor of poor outcome (n=3688; adjusted OR, 1.61; 95% CI, 1.44-1.79; P<0.0001). In post hoc analyses, including only leukoaraiosis patients in randomized controlled trials (IST-3 [third International Stroke Trial], NINDS [National Institute of Neurological Disorders and Stroke], ECASS-1-2 [European Cooperative Acute Stroke Study]; n=2234), tissue-type plasminogen activator versus control was associated with higher sICH risk (OR, 5.50; 95% CI, 2.49-12.13), but lower poor outcome risk (OR, 0.75; 95% CI, 0.60-0.95). CONCLUSIONS:Leukoaraiosis might increase post-intravenous thrombolysis sICH risk and poor outcome poststroke. Despite increased sICH risk, intravenous tissue-type plasminogen activator treatment has net clinical benefit in patients with leukoaraiosis. Given the risk of bias/confounding, these results should be considered hypothesis-generating and do not justify withholding intravenous thrombolysis.
10.1161/STROKEAHA.116.014096
Performance of blend sign in predicting hematoma expansion in intracerebral hemorrhage: A meta-analysis.
Yu Zhiyuan,Zheng Jun,Guo Rui,Ma Lu,Li Mou,Wang Xiaoze,Lin Sen,Li Hao,You Chao
Clinical neurology and neurosurgery
OBJECTIVES:Hematoma expansion is independently associated with poor outcome in intracerebral hemorrhage (ICH). Blend sign is a simple predictor for hematoma expansion on non-contrast computed tomography. However, its accuracy for predicting hematoma expansion is inconsistent in previous studies. This meta-analysis is aimed to systematically assess the performance of blend sign in predicting hematoma expansion in ICH. MATERIAL AND METHODS:A systematic literature search was conducted. Original studies about predictive accuracy of blend sign for hematoma expansion in ICH were included. Pooled sensitivity, specificity, positive and negative likelihood ratios were calculated. Summary receiver operating characteristics curve was constructed. Publication bias was assessed by Deeks' funnel plot asymmetry test. RESULTS:A total of 5 studies with 2248 patients were included in this meta-analysis. The pooled sensitivity, specificity, positive and negative likelihood ratios of blend sign for predicting hematoma expansion were 0.28, 0.92, 3.4 and 0.78, respectively. The area under the curve (AUC) was 0.85. No significant publication bias was found. CONCLUSION:This meta-analysis demonstrates that blend sign is a useful predictor with high specificity for hematoma expansion in ICH. Further studies with larger sample size are still necessary to verify the accuracy of blend sign for predicting hematoma expansion.
10.1016/j.clineuro.2017.10.017
Cortical superficial siderosis and bleeding risk in cerebral amyloid angiopathy: A meta-analysis.
Charidimou Andreas,Boulouis Gregoire,Greenberg Steven M,Viswanathan Anand
Neurology
OBJECTIVE:To assess the association of cortical superficial siderosis (cSS) presence and extent with future bleeding risk in cerebral amyloid angiopathy (CAA). METHODS:This was a meta-analysis of clinical cohorts of symptomatic patients with CAA who had T2*-MRI at baseline and clinical follow-up for future intracerebral hemorrhage (ICH). We pooled data in a 2-stage meta-analysis using random effects models. Covariate-adjusted hazard ratios (adjHR) from multivariable Cox proportional hazard models were used. RESULTS:We included data from 6 eligible studies (n = 1,239). cSS pooled prevalence was 34% (95% confidence interval [CI] 26%-41%; 87.94%; < 0.001): focal cSS prevalence was 14% (95% CI 12%-16%; 6.75%; = 0.37), and disseminated cSS prevalence was 20% (95% CI 13%-26%; 90.39%; < 0.001). During a mean follow-up of 3.1 years (range 1-4 years), 162/1,239 patients experienced a symptomatic ICH-pooled incidence rate 6.9% per year (95% CI 3.9%-9.8% per year; 83%; < 0.001). ICH incidence rates per year according to cSS status were 3.9% (95% CI 1.7%-6.1%; 70%; = 0.018) for patients without cSS, 11.1% (95% CI 7%-15.2%; 56.8%; = 0.074) for cSS presence, 9.1% (95% CI 5.5%-12.8%; 0%; = 0.994) for focal cSS, and 12.5% (95% CI 5.3%-19.7%; 73.2%; = 0.011) for disseminated cSS. In adjusted pooled analysis, any cSS presence was independently associated with increased future ICH risk (adjHR 2.14; 95% CI 1.19-3.85; < 0.0001). Focal cSS was linked with ICH risk (adjHR 2.11; 95% CI 1.31-2.41; = 0.002), while disseminated cSS conferred the strongest bleeding risk (adjHR 4.28; 95% CI 2.91-6.30; < 0.0001). CONCLUSION:In patients with CAA, cSS presence and extent are the most important MRI prognostic risk factors for future ICH, likely useful in treatment planning. CLASSIFICATION OF EVIDENCE:This study provides Class III evidence that in symptomatic CAA survivors with baseline T2*-MRI, cSS (particularly if disseminated, i.e., affecting >3 sulci) increases the risk of future ICH.
10.1212/WNL.0000000000008590
Accuracy of swirl sign for predicting hematoma enlargement in intracerebral hemorrhage: a meta-analysis.
Yu Zhiyuan,Zheng Jun,He Maiyue,Guo Rui,Ma Lu,You Chao,Li Hao
Journal of the neurological sciences
BACKGROUND:Hematoma enlargement happens in about 30% patients with intracerebral hemorrhage, which is reported to be closely correlated with poor prognosis. Swirl sign has been reported to have correlation with hematoma enlargement. This meta-analysis analyzed the accuracy of swirl sign for predicting hematoma enlargement in intracerebral hemorrhage. METHODS:Five databases were searched for potentially eligible literature. Studies were included if they were about the predictive properties of swirl sign for hematoma enlargement in intracerebral hemorrhage. Sensitivity and specificity of swirl sign for hematoma enlargement prediction were pooled. Pooled positive and negative likelihood ratios were also calculated. RESULTS:Six studies with 2647 patients were finally included in meta-analysis. The pooled sensitivity and specificity of swirl sign were 0.45 (95%CI 0.32-0.59) and 0.79 (95%CI 0.73-0.84), respectively. The pooled positive likelihood ratio of swirl sign was 2.2 (95%CI 1.8-2.5). In contrast, the pooled negative likelihood ratio of swirl sign was 0.69 (95%CI 0.57-0.84). CONCLUSIONS:This meta-analysis suggests that swirl sign has the relatively high specificity for hematoma enlargement prediction in patients with intracerebral hemorrhage.
10.1016/j.jns.2019.02.032
Meta-Analysis of Predictive Significance of the Black Hole Sign for Hematoma Expansion in Intracerebral Hemorrhage.
Zheng Jun,Yu Zhiyuan,Guo Rui,Li Hao,You Chao,Ma Lu
World neurosurgery
OBJECTIVE:Hematoma expansion is related to unfavorable prognosis in intracerebral hemorrhage (ICH). The black hole sign is a novel marker on non-contrast computed tomography for predicting hematoma expansion. However, its predictive values are different in previous studies. Thus, this meta-analysis was conducted to evaluate the predictive significance of the black hole sign for hematoma expansion in ICH. METHODS:A systematic literature search was performed. Original researches on the association between the black hole sign and hematoma expansion in ICH were included. Sensitivity and specificity were pooled to assess the predictive accuracy. Summary receiver operating characteristics curve (SROC) was developed. Deeks' funnel plot asymmetry test was used to assess the publication bias. RESULTS:Five studies with a total of 1495 patients were included in this study. The pooled sensitivity and specificity of the black hole sign for predicting hematoma expansion were 0.30 and 0.91, respectively. The area under the curve was 0.78 in SROC curve. There was no significant publication bias. CONCLUSIONS:This meta-analysis shows that the black hole sign is a helpful imaging marker for predicting hematoma expansion in ICH. Although the black hole sign has a relatively low sensitivity, its specificity is relatively high.
10.1016/j.wneu.2018.04.140
Heterogeneity Signs on Noncontrast Computed Tomography Predict Hematoma Expansion after Intracerebral Hemorrhage: A Meta-Analysis.
Zhang Danfeng,Chen Jigang,Xue Qiang,Du Bingying,Li Ya,Chen Tao,Jiang Ying,Hou Lijun,Dong Yan,Wang Junyu
BioMed research international
BACKGROUND AND PURPOSE:Hematoma expansion (HE) is related to clinical deterioration after intracerebral hemorrhage (ICH) and noncontrast computed tomography (NCCT) signs are indicated as predictors for HE but with inconsistent conclusions. We aim to clarify the correlations of NCCT heterogeneity signs with HE by meta-analysis of related studies. METHODS:PubMed, Embase, and Cochrane library were searched for eligible studies exploring the relationships between NCCT heterogeneity signs (hypodensity, mixed density, swirl sign, blend sign, and black hole sign) and HE. Poor outcome and mortality were considered as secondary outcomes. Odds ratio (OR) and its 95% confidence intervals (CIs) were selected as the effect size and combined using random effects model. RESULTS:Fourteen studies were included, involving 3240 participants and 435 HEs. The summary results suggested statistically significant correlations of heterogeneity signs with HE (OR, 5.17; 95% CI, 3.72-7.19, < 0.001), poor outcome (OR, 3.60; 95% CI, 1.98-6.54, < 0.001), and mortality (OR, 4.64; 95%, 2.96-7.27, < 0.001). CONCLUSIONS:Our findings suggested that hematoma heterogeneity signs on NCCT were positively associated with the increased risk of HE, poor outcome, and mortality rate in ICH.
10.1155/2018/6038193
Meta-Analysis of Accuracy of the Spot Sign for Predicting Hematoma Growth and Clinical Outcomes.
Phan Thanh G,Krishnadas Natasha,Lai Vivian Wai Yun,Batt Michael,Slater Lee-Anne,Chandra Ronil V,Srikanth Velandai,Ma Henry
Stroke
Background and Purpose- The computed tomography angiographic spot sign refers to contrast leakage within intracerebral hemorrhage (ICH). It has been proposed as a surrogate radiological marker for ICH growth. We conducted a meta-analysis to study the accuracy of the spot sign for predicting ICH growth and mortality. Methods- PubMed, Medline, conference proceedings, and article references in English up to June 2017 were searched for studies reporting "computed tomography angiography" and "spot sign" or "intracerebral hemorrhage" and "spot sign." Each study was ranked on 27 criteria resulting in a quality rating score. Bivariate random effect meta-analysis was used to calculate positive and negative likelihood ratios and area under summary receiver operating characteristics curve for ICH growth and mortality. Hematoma growth was defined using the change in ≥6 mL or ≥33% increase in volume. Results- There were 26 studies describing 5085 patients, including 15 studies not used in previous meta-analyses. Positive likelihood ratio and negative likelihood ratio for ICH growth were 4.85 (95% CI, 3.85-6.02; I=76.1%) and 0.49 (95% CI, 0.40-0.58) and mortality were 4.65 (95% CI, 3.67-5.90) and 0.55 (95% CI, 0.40-0.69), respectively. For ICH growth, the pooled sensitivity was 0.57 (95% CI, 0.49-0.64) and pooled false positive rate was 0.12 (95% CI, 0.09-0.14). The post-test probability of ICH growth was 0.57. The area under the curve for ICH growth and mortality was 0.86 and 0.87 (CIs are not provided in bivariate method). Meta-regression showed sensitivity of the test to decline significantly with subsequent year of publication (β=-0.148; 95% CI, -0.295 to -0.001; P=0.05). Higher quality assessment is associated with lower false positive rate (β=-0.074; 95% CI, -0.126 to -0.022; P=0.006). Conclusions- The high area under the curve potentially suggests that the spot sign can predict hematoma growth and mortality. Caution is recommended in its application given the heterogeneity across studies, which is appropriate given the data.
10.1161/STROKEAHA.118.024347
Accuracy of Shape Irregularity and Density Heterogeneity on Noncontrast Computed Tomography for Predicting Hematoma Expansion in Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis.
Yu Zhiyuan,Zheng Jun,Xu Zhao,Li Mou,Wang Xiaoze,Lin Sen,Li Hao,You Chao
World neurosurgery
OBJECTIVE:This systematic review and meta-analysis was aimed to evaluate the predictive values of shape irregularity and density heterogeneity of hematoma on noncontrast computed tomography (NCCT) for hematoma expansion (HE). METHODS:A literature search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane Library. Studies about predictive values of shape regularity or density heterogeneity of hematoma on NCCT for HE in spontaneous intracerebral hemorrhage were included. Meta-analysis was performed to pool the data. Publication bias assessment, subgroup analysis, and univariate meta-regression were conducted. RESULTS:A total of 7 studies with 2294 patients were included. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of shape irregularity were 67%, 47%, 1.30, and 0.71, respectively. In contrast, the pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of density irregularity were 52%, 69%, 1.70, and 0.69, respectively. CONCLUSIONS:Considering the relatively low sensitivity and specificity, the predictive values of shape irregularity and density heterogeneity of hematoma for HE are limited. Further studies are still needed to find optimal NCCT predictors for HE in spontaneous intracerebral hemorrhage patients.
10.1016/j.wneu.2017.09.022
CT Perfusion for Identification of Patients at Risk for Delayed Cerebral Ischemia during the Acute Phase after Aneurysmal Subarachnoid Hemorrhage: A Meta-analysis.
Neurology India
BACKGROUND:It has been acknowledged that delayed cerebral ischemia (DCI) can be diagnosed by computed tomography perfusion (CTP) when it occurs following aneurysmal subarachnoid hemorrhage (aSAH); however, the clinical role of CTP in the prediction of DCI remains unclear. We performed a meta-analysis to investigate the role of CTP in the identification of patients at risk for DCI during the acute phase (<4 days) after aSAH. MATERIALS AND METHODS:Relevant articles were systematically searched for analysis on PubMed, EMBASE, and Cochrane databases. The best CTP parameter or the definition of abnormal CTP scan result were collected, and the data with the greatest overall predictive value for DCI was extracted to assess the strength of association between a positive CTP result and an impending DCI. In addition, pooled estimates of sensitivity and specificity were determined. RESULTS:Three relevant articles involving 128 patients were included in the analysis wherein DCI developed in 48 patients (37.5%). The pooled odds ratio was 32.15 (95% CI, 9.92-104.21), suggesting that the patients with a positive CTP test in the acute phase after aSAH were approximately 32 times as likely to develop DCI compared with those without aSAH. The pooled sensitivity and specificity of CTP for detecting impending DCI after aSAH was 65% (95% CI: 0.49-0.78) and 91% (95% CI: 0.83-0.96). CONCLUSIONS:CTP can detect abnormal brain perfusion before the occurrence of DCI. This may allow close monitoring and preemptive therapy for improvement in the prognosis in patients with aSAH.
10.4103/0028-3886.271235
Predictive Accuracy of Alpha-Delta Ratio on Quantitative Electroencephalography for Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis.
Yu Zhiyuan,Wen Dingke,Zheng Jun,Guo Rui,Li Hao,You Chao,Ma Lu
World neurosurgery
OBJECTIVE:Delayed cerebral ischemia (DCI) is significantly related to death and unfavorable functional outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). The association between alpha-delta ratio (ADR) on quantitative electroencephalography (EEG) and DCI has been reported in several previous studies, but their results are conflicting. This meta-analysis was conducted to assess the accuracy of ADR for DCI prediction in patients with aneurysmal SAH. METHODS:PubMed and Embase were systematically searched for related records. Study selection and data collection were completed by 2 investigators. Sensitivity, specificity, and their 95% confidence intervals (CIs) were pooled. A summary receiver operating characteristic curve was plotted to show the pooled accuracy. Deeks funnel plot was used to evaluate publication bias. RESULTS:Five studies were included in this meta-analysis. The pooled sensitivity and specificity of worsening ADR for DCI prediction in patients with aneurysmal SAH were 0.83 (95% CI 0.44-0.97) and 0.74 (95% CI 0.50-0.89), respectively. In addition, the area under the summary receiver operating characteristic curve was 0.84 (95% CI 0.81-0.87). No obvious publication bias was found using Deeks funnel plot (P = 0.29). CONCLUSIONS:Worsening ADR on quantitative EEG is a reliable predictor of DCI in patients with aneurysmal SAH. Further studies are still needed to confirm the role of quantitative EEG in DCI prediction.
10.1016/j.wneu.2019.02.082
Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.
Kumar Gyanendra,Shahripour Reza Bavarsad,Harrigan Mark R
Journal of neurosurgery
OBJECT The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. METHODS MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. RESULTS Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I(2) > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). CONCLUSIONS TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact of TCD monitoring on patient-centered and physician-relevant outcomes are needed.
10.3171/2015.4.JNS15428
High incidence of asymptomatic cerebral microbleeds in patients with hemorrhagic onset-type moyamoya disease: a phase-sensitive MRI study and meta-analysis.
Qin Ying,Ogawa Toshihide,Fujii Shinya,Shinohara Yuki,Kitao Shin-Ichiro,Miyoshi Fuminori,Takasugi Marie,Watanabe Takashi,Kaminou Toshio
Acta radiologica (Stockholm, Sweden : 1987)
BACKGROUND:Moyamoya disease is a relatively rare cerebrovascular occlusive disorder. Several studies have reported cerebral microbleeds (CMBs) in moyamoya disease patients using T2*-weighted imaging (T2*WI) and/or susceptibility-weighted imaging (SWI). PURPOSE:To investigate the incidence, distribution patterns, and influencing factors of asymptomatic CMBs in patients with moyamoya disease. MATERIAL AND METHODS:Phase-sensitive imaging (PSI) was used to investigate 27 consecutive moyamoya disease patients with a 3-T magnetic resonance imaging system, then a meta-analysis of 245 patients (asymptomatic moyamoya disease, n = 23; ischemic moyamoya disease, n = 161; hemorrhagic moyamoya disease, n = 61) from four previous individual studies and our PSI study was performed. The meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Based on the clinical and radiological data, we divided the studies into different model groups to calculate the incidence of CMBs and discuss the distribution patterns of CMBs. RESULTS:Thirty-five asymptomatic CMBs were demonstrated in 14 moyamoya disease patients (51.9%) in our PSI study. Of these, 45.7% were located in the periventricular white matter. In the meta-analysis, the pooled incidence of asymptomatic CMBs in moyamoya disease was 46% (95% confidence interval [CI], 28.2-63.8%) on SWI or PSI and 29.6% (95% CI, 17.4-41.7%) on T2*WI. Statistical analysis showed that PSI or SWI offered better detection of CMBs in moyamoya disease than T2*WI, and 3-T T2*WI offered better detection than 1.5-T T2*WI. Furthermore, hemorrhagic onset-type moyamoya disease correlated with a high incidence of asymptomatic CMBs. CONCLUSION:PSI or SWI can detect CMBs better than T2*WI, and 3-T T2*WI. Hemorrhagic onset-type moyamoya disease seems to correlate with a high incidence of asymptomatic CMBs. The meta-analysis indicates that asymptomatic CMBs may be an important factor for hemorrhagic stroke risk. Long-term evaluation of CMBs using PSI or SWI may contribute to the management of moyamoya disease.
10.1177/0284185114524198
MRI for prediction of hemorrhagic transformation in acute ischemic stroke: a systematic review and meta-analysis.
Suh Chong Hyun,Jung Seung Chai,Cho Se Jin,Woo Dong-Cheol,Oh Woo Yong,Lee Jong Gu,Kim Kyung Won
Acta radiologica (Stockholm, Sweden : 1987)
BACKGROUND:Hemorrhagic transformation increases mortality and morbidity in patients with acute ischemic stroke. PURPOSE:The purpose of this study is to evaluate the diagnostic performance of magnetic resonance imaging (MRI) for prediction of hemorrhagic transformation in acute ischemic stroke. MATERIAL AND METHODS:A systematic literature search of MEDLINE and EMBASE was performed up to 27 July 2018, including the search terms "acute ischemic stroke," "hemorrhagic transformation," and "MRI." Studies evaluating the diagnostic performance of MRI for prediction of hemorrhagic transformation in acute ischemic stroke were included. Diagnostic meta-analysis was conducted with a bivariate random-effects model to calculate the pooled sensitivity and specificity. Subgroup analysis was performed including studies using advanced MRI techniques including perfusion-weighted imaging, diffusion-weighted imaging, and susceptibility-weighted imaging. RESULTS:Nine original articles with 665 patients were included. Hemorrhagic transformation is associated with high permeability, hypoperfusion, low apparent diffusion coefficient (ADC), and FLAIR hyperintensity. The pooled sensitivity was 82% (95% confidence interval [CI] 61-93) and the pooled specificity was 79% (95% CI 71-85). The area under the hierarchical summary receiver operating characteristic curve was 0.85 (95% CI 0.82-0.88). Although study heterogeneity was present in both sensitivity (I=67.96%) and specificity (I=78.93%), a threshold effect was confirmed. Studies using advanced MRI showed sensitivity of 92% (95% CI 70-98) and specificity of 78% (95% CI 65-87) to conventional MRI. CONCLUSION:MRI may show moderate diagnostic performance for predicting hemorrhage in acute ischemic stroke although the clinical significance of this hemorrhage is somewhat uncertain.
10.1177/0284185119887593