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  • Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day

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Cerebrovascular disease
Research paper
Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day
  1. Sapna Rawal1,2,
  2. Paula Alcaide-Leon3,
  3. R Loch Macdonald4,
  4. Gabriel J E Rinkel5,
  5. J Charles Victor2,6,
  6. Timo Krings1,
  7. Moira K Kapral2,6,7,
  8. Andreas Laupacis2,6,8
  1. 1Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  2. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  3. 3Division of Neuroradiology, Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
  4. 4Division of Neurosurgery, Department of Surgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
  5. 5Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
  6. 6Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  7. 7Division of General Internal Medicine, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
  8. 8Department of Medicine, St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
  1. Correspondence to Dr Sapna Rawal, Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, 399 Bathurst Street, McL Wing, 3rd Floor, Room 419, Toronto, ON, Canada M5T 2S8; sapna.rawal{at}uhn.ca

Abstract

Background and purpose To systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid haemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality.

Methods We searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I2 index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias.

Results 16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I2=0%)) but not when compared with treatment at 1–3 days (OR=1.16 (95% CI 0.47 to 2.90; I2=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I2=73%; OR=0.71 (95% CI 0.36 to 1.37; I2=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I2=34%) for treatment <1 day vs days 1–3; OR=1.71 (95% CI 0.72 to 4.03; I2=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I2=48%) for treatment <3 days vs later).

Conclusions In only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients.

http://dx.doi.org/10.1136/jnnp-2016-314596

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    Footnotes

    • Contributors SR conceptualised project, wrote protocol, designed data extraction form, performed literature search, identified studies for inclusion, contacted authors, extracted data, synthesised and analysed data and drafted manuscript. PA-L identified studies for inclusion, extracted data, reviewed data synthesis and analysis and reviewed manuscript. RLM conceptualized project, reviewed protocol, reviewed data synthesis and analysis and reviewed manuscript. GJER reviewed protocol, reviewed data synthesis and analysis and revised manuscript. JCV conceptualized project, reviewed protocol, reviewed data synthesis and analysis and reviewed manuscript. TK reviewed protocol, reviewed data synthesis and analysis and reviewed manuscript. MKK conceptualized project, reviewed protocol, reviewed data synthesis and analysis and reviewed manuscript. AL conceptualized project, revised protocol, reviewed data synthesis and analysis and revised manuscript.

    • Funding SR is supported by an Association of University Radiologists GE Radiology Research Academic Fellowship Award.

    • Competing interests PA-L receives grant support from Novartis. RLM receives grant support from the Physicians Services Incorporated Foundation, Brain Aneurysm Foundation, Canadian Institutes for Health Research and the Heart and Stroke Foundation of Canada; and is an employee and Chief Scientific Officer of Edge Therapeutics. MKK is supported by a Career Investigator Award from the Heart and Stroke Foundation of Canada, Ontario Provincial Office.

    • Provenance and peer review Not commissioned; externally peer reviewed.