Artikel
Effect of medical treatment on the prevention of radiological vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage – a systematic review and meta-analysis
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Autoren
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Nima Etminan
- University of Toronto, Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada; Heinrich-Heine Universität, Neurochirurgische Klinik, Düsseldorf, Deutschland
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Mervyn D. Vergouwen
- University of Toronto, Division of Neurology, Toronto Western Hospital, Toronto, Canada
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Daniel Hänggi
- Heinrich-Heine Universität, Neurochirurgische Klinik, Düsseldorf, Deutschland
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Hans-Jakob Steiger
- Heinrich-Heine Universität, Neurochirurgische Klinik, Düsseldorf, Deutschland
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R. Loch Macdonald
- University of Toronto, Division of Neurosurgery, St. Michael's Hospital, Toronto, Canada
| Veröffentlicht: | 16. September 2010 |
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Gliederung
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Objective: Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage is a major cause of morbidity and mortality after acute treatment of ruptured intracranial aneurysms. The pathogenesis of DCI remains unclear. Since radiological vasospasm is strongly associated with the occurrence of DCI, clinical trials in the last few decades focused on the prevention of radiological vasospasm to prevent clinical features of DCI. However, data are accumulating that additional mechanisms, such as microthrombosis and cortical spreading ischemia, might play a role in the pathogenesis of DCI. We decided to perform a systematic review of all randomized placebo controlled trials that investigated the efficacy of drugs on the prevention of DCI to further study the relationship between radiological vasospasm and DCI.
Methods: All randomized, double-blinded, placebo-controlled trials that studied the efficacy of medical treatment on the prevention of both radiological vasospasm and DCI were included. Outcome events were the number of patients with vasospasm (as measured by transcranial Doppler sonography and/or cerebral angiography) and clinical features of DCI. Effects were expressed in (pooled) risk ratio estimates. Data were pooled using random-effect models.
Results: In total, 32 trials were identified that study any medical treatment strategy to prevent vasospasm/DCI. Twelve studies that included 2,222 patients had both radiological vasospasm and clinical features of DCI as an outcome event. Despite a significant reduction of radiological vasospasm (RR 0.78 (95% CI 0.71–0.85)) no statistically significant effect on clinical features of DCI was observed in the pooled analysis (RR 0.89 (95% 0.76–1.03)).
Conclusions: The results of this systematic review show that medical treatment strategies in SAH patients decrease the incidence of radiological vasospasm but not of clinical features of DCI. Our data support the hypothesis that besides radiological vasospasm other mechanisms are involved in the pathogenesis of DCI, and might give an explanation why only little progress has been made in the last decades in the prevention of DCI after SAH.
