BackgroundIn anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent.MethodsIn April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality.ResultsFour RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27).ConclusionsOur study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH.Protocol registration number(PROSPERO ID: CRD42021236092).

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La adherencia de investigación en la formación médica es capaz de atender la demanda de una sociedad en constante evolución, dando como resultado profesionales con capacidad creativa y analitica donde tomen decisiones basadas en la investigación científica para el bien de la salud individual y colectiva 1. La información científica fluye a una velocidad nunca antes vista y la medicina es parte de esta tendencia mundial. Día a día se publican decenas de artículos en diferentes revistas y bases de datos, los que continúan alimentando el conocimiento médico. Por lo tanto, se considera indispensable para la construcción de nuevas realidades invertir en programas de educación médica 2 .

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Introduction Paraclinoid aneurysms (PAs) have traditionally been treated with clipping. However, with the emergence of new techniques, endovascular treatment (EVT) has supplanted surgical treatment in recent years. We aimed to determine the safety and efficacy of EVT and microsurgical clipping for PAs. Methods A systematic review was performed in Scopus, Embase, Medline, Web of Science, and Cochrane from inception to March 2022 for all studies that tested the safety and efficacy of EVT or microsurgical clipping of PAs. Efficacy outcomes included complete aneurysm occlusion at last follow‐up, immediate complete occlusion, and an mRS 0–2 at last follow‐up. Safety outcomes included mortality, intraoperative and postoperative complications. We performed a random‐effects meta‐analysis of proportions and assessed the statistical heterogeneity across studies with I2 statistics. Results Eighty‐nine studies included 6496 patients, 3682 treated with EVT and 2814 with microsurgical clipping. Immediate complete occlusion rates were 92% (95% CI 88 – 96%; I2 = 60%) and 46% (95% CI 34 – 59%; I2 = 93%) for clipping and EVT, respectively. The rate of complete occlusion at last follow‐up was 94% (95% CI 91 – 96%; I2 = 0%) and 69% (95% CI 63 – 74%; I2 = 79%) for microsurgical clipping and EVT, respectively. Among EVT studies, the rate of complete occlusion was 54% (95% CI 48 – 59%; I2 = 50%), 52% (95% CI 39 – 64%; I2 = 73%), and 77% (95% CI 54 – 91%; I2 = 91%) for primary coiling, stent‐assisted coiling, and flow diversion, respectively. Among clipping studies, the rate of last follow‐up mRS 0–2 was 86% (95% CI 76 – 92%; I2 = 72%). Among EVT studies, the rate of last follow‐up mRS 0–2 was 94% (95% CI 86 – 98%; I2 = 93%). Mortality rate was 4% (95% CI 3 – 7%; I2 = 57%) and 1% (95% CI 0 – 3%; I2 = 0%) for clipping and EVT, respectively. Among EVT studies, the mortality rate was 3% (95% CI 1 – 6%; I2 = 0%) and 3% (95% CI 1 – 9%; I2 = 39%) for primary coiling and flow diversion, respectively. Intraoperative and postoperative complications were present in 9% (95% CI 6 – 14%; I2 = 68%) and 21% (95% CI 17 – 26%; I2 = 87%) among clipping studies, respectively. Intraoperative and postoperative complications were present in 6% (95% CI 4 – 9%; I2 = 64%) and 9% (95% CI 6 – 13%; I2 = 72%) among EVT studies, respectively. Conclusions In conclusion, microsurgical clipping and EVT for PAs are both safe and effective treatment modalities. Treatment via either approach should be determined on a case‐by‐case basis and according to institutional experience and resources.

Conflictos de interés:Los autores declaran no tener conflictos de interés.