No abstract

This article is available at e-publications@RCSI: http://epubs.rcsi.ie/gerstrmedart/1 -Use LicenceThis work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License.This article is available at e-publications@RCSI: http://epubs.rcsi.ie/gerstrmedart/1T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med nejm.org

Long-term monitoring of patients treated by endosaccular coiling is mandatory.

Background and Purpose-We sought to better define the morbidity of endovascular Guglielmi detachable coil (GDC) treatment of unruptured cerebral aneurysms and to discuss its role in the prevention of subarachnoid hemorrhage. in 53 aneurysms (42.4%), leaving 6 residual aneurysms (4.8%) and 7 failures (5.6%). Early follow-up angiograms, available in 100 treated aneurysms (84%), revealed class 1 in 52% and class 2 in 41%. Intermediate angiograms, available in 53 aneurysms (44.5%), showed class 1 in 47.2% and class 2 in 43.4%, while late results, available in 37 lesions (31.1%), had class 1 and 2 in 48.6% and 37.8%, respectively. Six patients suffered a permanent neurological deficit at last follow-up (5.2%), with a good outcome in 5 patients and fair outcome in 1 patient. There was no mortality. There was no aneurysmal rupture during a mean clinical follow-up of 32.1 months. Conclusions-Endovascular treatment with GDC for unruptured aneurysms is relatively safe. Its role in the prevention of aneurysmal rupture remains to be determined, preferably by a randomized study. Methods

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Campbell, B. C.V. et al. (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.ABSTRACT Background: CT-perfusion (CTP) and MRI may assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of ischaemic core and penumbra volumes were associated with functional outcomes and treatment effect.

Campbell, B. C. V. et al. (2018) Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurology, 17(1), pp. 47-53. (doi:10.1016/S1474-4422(17)30407-6) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/149670/ variables. An alternative approach using propensity-score stratification was also used. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models. Bias was assessed using the Cochrane tool.Findings: Of 1764 patients in 7 trials, 871 were allocated to endovascular thrombectomy. After exclusion of 74 patients (72 who did not undergo the procedure and 2 with missing data on anaesthetic strategy), 236/797 (30%) of endovascular patients were treated under GA. At baseline, GA patients were younger and had shorter time to randomisation but similar pre-treatment clinical severity compared to non-GA. Endovascular thrombectomy improved functional outcome at 3 months versus standard care in both GA (adjusted common odds ratio (cOR) 1·52, 95%CI 1·09-2·11, p=0·014) and non-GA (adjusted cOR 2·33, 95%CI 1·75-3·10, p<0·001) patients. However, outcomes were significantly better for those treated under non-GA versus GA (covariate-adjusted cOR 1·53, 95%CI 1·14-2·04, p=0·004; propensitystratified cOR 1·44 95%CI 1·08-1·92, p=0·012). The risk of bias and variability among studies was assessed to be low.Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding:The HERMES collaboration was funded by an unrestricted grant from Medtronic to the University of Calgary. Research in contextEvidence before this study between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of general anaesthesia versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of general anaesthesia. Added value of this studyThese data from contemporary, high quality randomised trials form the largest study to date of the association between general anesthesia and the benefit of endovascular thrombectomy versus standard care. We used two different approaches to adjust for baseline imbalances (multivariable logistic regression and propensity-score stratification). We found that GA for endovascular thrombectomy, as practiced in contemporary clinical care across a wide range of expert centres during the rand...

SUMMARY:In medical research analyses, continuous variables are often converted into categoric variables by grouping values into Ն2 categories. The simplicity achieved by creating Ն2 artificial groups has a cost: Grouping may create rather than avoid problems. In particular, dichotomization leads to a considerable loss of power and incomplete correction for confounding factors. The use of data-derived "optimal" cut-points can lead to serious bias and should at least be tested on independent observations to assess their validity. Both problems are illustrated by the way the results of a registry on unruptured intracranial aneurysms are commonly used. Extreme caution should restrict the application of such results to clinical decision-making. Categorization of continuous data, especially dichotomization, is unnecessary for statistical analysis. Continuous explanatory variables should be left alone in statistical models.ABBREVIATIONS: ACA ϭ anterior cerebral artery; CHUM ϭ Centre hospitalier de l'Université de Montré al; ICA ϭ internal carotid artery; ISUIA ϭ International Study of Unruptured Intracranial Aneurysms; MCA ϭ middle cerebral artery; Pcirc ϭ posterior circulation; PcomA ϭ posterior communicating artery; SAH ϭ subarachnoid hemorrhage; UIA ϭ unruptured intracranial aneurysms U IAs are common (approximately 2% of the adult population), but they most often remain silent until a rupture occurs (incidence, 2-20/10,000/year).1 No one is sure what to do with them, but with the increasing accessibility of noninvasive imaging of the brain, the problem is growing rapidly. 2A common and yet controversial approach to decisionmaking is to compare the natural history of the disease and the risks of treatment.3,4 One prominent risk factor for rupture of UIAs is size. In 1998, a landmark study on this subject, the ISUIA, estimated from retrospectively obtained data that the risk of rupture of aneurysms smaller than 10 mm was extremely low.5 Subsequent guidelines published in 2000 discouraged the treatment of aneurysms smaller than that size. 6In a 2003 study, the same group, confronted with different results when data were collected prospectively, claimed that aneurysms Ͻ7 mm in a special subgroup of patients (defined by the absence of a history of rupture of another lesion, having an aneurysm located in the anterior circulation, and selected for observation) were at zero risk of rupture, but only when some carotid aneurysms were excluded (PcomA aneurysms). 7Despite these specifications, a threshold of 7 mm is now used by many as a normative criterion for clinical decisions 8 or in cost-effectiveness analyses. 9Size of UIAs can serve to illustrate the problems associated with the categorization of continuous variables, in particular dichotomization. Our aim is to consider how continuous variables should be treated and analyzed when we suspect that risk increases or decreases in proportion to the variable in question. We address the following questions: What are the advantages and disadvantages of categorization? If we de...