Endovascular treatment for acute ischemic stroke in octogenarians compared with younger patients: a meta-analysis.

BACKGROUND: Little is known about the safety and efficacy of endovascular therapy for acute ischemic stroke in octogenarians. AIM: We performed a systematic review and meta-analysis of published studies comparing outcomes of octogenarians and younger patients after endovascular treatment for acute ischemic stroke. METHODS: A computerized search of the medical literature from 1990 to 2012 was performed to identify comparative studies of endovascular treatment of ischemic stroke patients 80 years or older and younger patients. Data on clinical outcomes, mortality, symptomatic intracerebral hemorrhage, and recanalization were abstracted. RESULTS: Data from eight studies with 2729 patients were included in the final analysis. Good functional outcome defined as modified Rankin score 2 or less within 90 days was more common in younger patients compared with octogenarians [odds ratio 2.694; 95% confidence interval 1.941-3.740, P < 0.001). Symptomatic hemorrhage and death were significantly more come in patients 80 years or older (odds ratio 1.604; 95% confidence interval 1.013-2.540, P = 0.04 and odds ratio 3.695; 95% confidence interval 2.517-5.424, P < 0.001, respectively). Successful recanalization defined as Thrombolysis in Myocardial Infarction (TIMI) 2-3 was seen less frequently in older patients; however, this did not reach statistical significance (odds ratio 0.814; 95% confidence interval 0.522-1.269, P = 0.364). CONCLUSION: Formal meta-analysis showed that octogenarians are less likely to achieve functional independence and have higher rates of mortality and intracerebral hemorrhage following endovascular treatment for ischemic stroke compared with younger patients. Decisions regarding endovascular treatment of elderly patients should be individualized until randomized controlled trials are available.

Recent advances in neuroendovascular therapy.

The field of neurointerventional surgery has grown in recent years. Endovascular therapies for both ischemic stroke and intracranial aneurysms have become important components in the multimodal treatment of these conditions. Familiarity with these treatment options by general neurologists is important for patient care. This article reviews recent trials and devices representing important advances in the field.

Cost-effectiveness of digital subtraction angiography in the setting of computed tomographic angiography negative subarachnoid hemorrhage.

BACKGROUND: Recent studies have documented the high sensitivity of computed tomography angiography (CTA) in detecting a ruptured aneurysm in the presence of acute subarachnoid hemorrhage (SAH). The practice of digital subtraction angiography (DSA) when CTA does not reveal an aneurysm has thus been called into question. OBJECTIVE: We examined this dilemma from a cost-effectiveness perspective by using current decision analysis techniques. METHODS: A decision tree was created with the use of TreeAge Pro Suite 2012; in 1 arm, a CTA-negative SAH was followed up with DSA; in the other arm, patients were observed without further imaging. Based on literature review, costs and utilities were assigned to each potential outcome. Base-case and sensitivity analyses were performed to determine the cost-effectiveness of each strategy. A Monte Carlo simulation was then conducted by sampling each variable over a plausible distribution to evaluate the robustness of the model. RESULTS: With the use of a negative predictive value of 95.7% for CTA, observation was found to be the most cost-effective strategy ($6737/Quality Adjusted Life Year [QALY] vs $8460/QALY) in the base-case analysis. One-way sensitivity analysis demonstrated that DSA became the more cost-effective option if the negative predictive value of CTA fell below 93.72%. The Monte Carlo simulation produced an incremental cost-effectiveness ratio of $83 083/QALY. At the conventional willingness-to-pay threshold of $50 000/QALY, observation was the more cost-effective strategy in 83.6% of simulations. CONCLUSION: The decision to perform a DSA in CTA-negative SAH depends strongly on the sensitivity of CTA, and therefore must be evaluated at each center treating these types of patients. Given the high sensitivity of CTA reported in the current literature, performing DSA on all patients with CTA negative SAH may not be cost-effective at every institution.

Accuracy of computed tomographic angiography compared to digital subtraction angiography in the diagnosis of intracranial stenosis and its impact on clinical decision-making.

BACKGROUND: Few studies to date have examined the accuracy of computed tomographic angiography (CTA) compared to digital subtraction angiography (DSA) in diagnosing intracranial stenosis. The purpose of this study was to compare CTA to DSA in diagnosing intracranial stenosis and to explore the impact of the addition of DSA on the management of stroke patients. METHODS: We retrospectively reviewed all ischemic stroke or patients with transient ischemic attack who underwent CTA and DSA within 30 days of each other at our institution between January 2008 and July 2011. For each study, 2 blinded observers rated the degree of stenosis of 11 intracranial vessels. Disagreements were adjudicated by a third blinded observer. Sensitivity, specificity, negative predictive value, and receiver operating characteristic curves were determined using DSA as the criterion standard. All patient charts were reviewed to determine if the addition of DSA to CTA impacted clinical management. RESULTS: Six hundred twenty-seven arterial segments were reviewed. The sensitivity of CTA to diagnose stenosis >50% was 96.6% (95% confidence interval [CI] 88.1-99.6), specificity 99.4% (95% CI 98.1-99.9), and negative predictive value 99.6% (95% CI 98.4-99.9). The intraclass correlation between CTA and DSA measurements was 0.96 (95% CI 0.95-0.97). Five of 57 patients underwent intracranial stenting procedures during the study period. All 5 lesions were correctly characterized as having >70% stenosis on CTA. Of the remaining 52 patients, none had clinical management change based on DSA findings. CONCLUSIONS: CTA has a high sensitivity and specificity compared to DSA to diagnose intracranial stenosis. The addition of DSA to CTA may not affect clinical management in most patients with suspected stenosis.

Head, neck, and brain tumor embolization guidelines.

BACKGROUND: Management of vascular tumors of the head, neck, and brain is often complex and requires a multidisciplinary approach. Peri-operative embolization of vascular tumors may help to reduce intra-operative bleeding and operative times and have thus become an integral part of the management of these tumors. Advances in catheter and non-catheter based techniques in conjunction with the growing field of neurointerventional surgery is likely to expand the number of peri-operative embolizations performed. The goal of this article is to provide consensus reporting standards and guidelines for embolization treatment of vascular head, neck, and brain tumors. SUMMARY: This article was produced by a writing group comprised of members of the Society of Neurointerventional Surgery. A computerized literature search using the National Library of Medicine database (Pubmed) was conducted for relevant articles published between 1 January 1990 and 31 December 2010. The article summarizes the effectiveness and safety of peri-operative vascular tumor embolization. In addition, this document provides consensus definitions and reporting standards as well as guidelines not intended to represent the standard of care, but rather to provide uniformity in subsequent trials and studies involving embolization of vascular head and neck as well as brain tumors. CONCLUSIONS: Peri-operative embolization of vascular head, neck, and brain tumors is an effective and safe adjuvant to surgical resection. Major complications reported in the literature are rare when these procedures are performed by operators with appropriate training and knowledge of the relevant vascular and surgical anatomy. These standards may help to standardize reporting and publication in future studies.

The natural history and treatment options for unruptured intracranial aneurysms.

Recent advances in angiographic technique have raised our awareness of the presence of unruptured intracranial aneurysms (UIAs). However, the appropriate management for these lesions remains controversial. To optimize patient outcomes, the physician must weigh aneurysmal rupture risk associated with observation against the complication risks associated with intervention. In the case that treatment is chosen, the two available options are surgical clipping and endovascular coiling. Our paper summarizes the current body of literature in regards to the natural history of UIAs, the evolution of the lesion if it progresses uninterrupted, as well as the safety and efficacy of both treatment options. The risks and benefits of treatment and conservative management need to be evaluated on an individual basis and are greatly effected by both patient-specific and aneurysm-specific factors, which are presented in this paper. Ultimately, this body of data has led to multiple sets of treatment guidelines, which we have summated and presented in this paper.

Advanced neuroimaging in acute ischemic stroke: extending the time window for treatment.

Early treatment of ischemic stroke with thrombolytics is associated with improved outcomes, but few stroke patients receive thrombolytic treatment in part due to the 3-hour time window. Advances in neuroimaging may help to aid in the selection of patients who may still benefit from thrombolytic treatment beyond conventional time-based guidelines. In this article the authors review the available literature in support of using advanced neuroimaging to select patients for treatment beyond the 3-hour time window cutoff and explore potential applications and limitations of perfusion imaging in the treatment of acute ischemic stroke.

Cardiac workup of ischemic stroke: can we improve our diagnostic yield?

BACKGROUND AND PURPOSE: Discovering potential cardiac sources of stroke is an important part of the urgent evaluation of the ischemic stroke patient as it often impacts treatment decisions that are essential for determining secondary stroke prevention strategies, yet the optimal approach to the cardiac workup of an ischemic stroke patient is not known. METHODS: A review of the literature concerning the utility of cardiac rhythm monitoring (ECG, telemetry, Holter monitors, and event recorders) and structural imaging (transthoracic and transesophageal echocardiography) was performed. RESULTS: Data supporting a definitive, optimal, and cost-effective approach are lacking, though some data suggest that appropriate patient selection can improve the diagnostic and therapeutic yield of rhythm monitoring and echocardiography in the evaluation of stroke etiology. CONCLUSIONS: Based on available data, an algorithmic approach for the evaluation of patients with acute ischemic cerebrovascular events that takes into account therapeutic and diagnostic yield as well as cost-efficiency is proposed.