显微外科治疗883例先前卷曲的颅内动脉瘤:有效性和安全性的系统回顾、meta分析和meta回归

IF 3.6 2区 医学 Q1 CLINICAL NEUROLOGY
Keng Siang Lee, Oliver Wroe-Wright, John J Y Zhang, Ahilan Kailaya-Vasan, Ramez Kirollos, Julian Han, Pascal Jabbour, Michael T Lawton
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引用次数: 0

摘要

目的:随着血管内栓塞术治疗颅内动脉瘤的数量不断增加,残留和复发的动脉瘤也越来越多。本研究旨在评估显微外科治疗这些先前卷曲的IAs的有效性和安全性。方法:系统检索Medline、Embase和Cochrane Central数据库。在最后一次随访时,主要结局是良好的功能结局(改良Rankin量表评分0-2分或格拉斯哥结局量表评分4-5分)和不变/改善的功能结局。次要结局包括术中破裂、影像学证实的完全闭塞、围手术期并发症和30天内死亡。结果:39项研究报告了874例患者的883例既往经显微手术处理的螺旋状IAs,纳入meta分析。在883例IAs中,分别有656例(74.3%)、167例(18.9%)、44例(5.0%)和16例(1.8%)进行了直接剪接、剪接并去除线圈、旁路和捕获。古里安A、B、c组分别有45例(5.1%)、806例(91.3%)和32例(3.6%),分别位于前、后分别占88.2%和11.8%;< 7 mm占45.3%,7 ~ 12 mm占31.3%,13 ~ 24 mm占14.6%,bb0 ~ 25 mm占8.8%。总体平均临床随访时间为33.7个月。术中破裂、围术期卒中和死亡的总体比例分别为0.1% (95% CI 0.0%-1.1%, I2 = 25.2%)、8.2% (95% CI 5.85%-11.34%, I2 = 52.8%)和3.7% (95% CI 2.63%-5.24%, I2 = 0.0%)。完全闭塞、良好和功能改善/不变的比例分别为97.2% (95% CI 95.82%-98.13%, I2 = 0.0%)、82.9% (95% CI 79.67%-85.69%, I2 = 5.1%)和92.3% (95% CI 89.27%-94.54%, I2 = 0.0%)。直接夹持未破裂的前循环IAs与术中破裂、围术期卒中和死亡的比例最低相关。直接夹持也与最大比例的完全闭塞、良好的功能预后和改善/不变的神经预后相关。Gurian C组血管内盘绕术1个月内的显微手术与围手术期死亡的比例较高。结论:在精心挑选的患者中,显微外科治疗先前卷曲的IAs是有效和安全的策略。在处理这些内瘘时需要考虑的重要因素包括内瘘的大小和位置、初次出现时的破裂状态、显微手术的适应证以及显微手术的类型和时机。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Microsurgical management of 883 previously coiled intracranial aneurysms: a systematic review, meta-analysis, and meta-regression of its effectiveness and safety.

Objective: With the increasing number of intracranial aneurysms (IAs) treated by endovascular coiling, more residual and recurrent IAs are being encountered. This study aimed to evaluate the effectiveness and safety of the microsurgical management of these previously coiled IAs.

Methods: Systematic searches of the Medline, Embase, and Cochrane Central databases were performed. The primary outcome was good functional outcome (modified Rankin Scale score 0-2 or Glasgow Outcome Scale score 4-5) and unchanged/improved functional outcomes at the last follow-up. Secondary outcomes included intraoperative rupture, complete occlusion confirmed on imaging, and perioperative complications and death within 30 days.

Results: Thirty-nine studies reporting on 874 patients with 883 previously coiled IAs managed by microsurgery were included in the meta-analysis. Of the 883 IAs, 656 (74.3%), 167 (18.9%), 44 (5.0%), and 16 (1.8%) underwent direct clipping, clipping with coil removal, bypass, and trapping, respectively. Forty-five (5.1%), 806 (91.3%), and 32 (3.6%) IAs were classified as Gurian group A, B, and C. IAs were located anteriorly in 88.2% and posteriorly in 11.8%; 45.3% were < 7 mm, 31.3% were 7-12 mm, 14.6% were 13-24 mm, and 8.8% were > 25 mm. The overall mean clinical follow-up duration was 33.7 months. Overall proportions of intraoperative rupture, perioperative stroke, and death were 0.1% (95% CI 0.0%-1.1%, I2 = 25.2%), 8.2% (95% CI 5.85%-11.34%, I2 = 52.8%), and 3.7% (95% CI 2.63%-5.24%, I2 = 0.0%), respectively. The proportions of complete occlusion, good, and improved/unchanged functional outcomes were 97.2% (95% CI 95.82%-98.13%, I2 = 0.0%), 82.9% (95% CI 79.67%-85.69%, I2 = 5.1%), and 92.3% (95% CI 89.27%-94.54%, I2 = 0.0%), respectively. Direct clipping of unruptured anterior circulation IAs was associated with the lowest proportion of intraoperative rupture, perioperative stroke, and death. Direct clipping was also associated with the greatest proportion of complete occlusion, good functional outcome, and improved/unchanged neurological outcome. Microsurgery within 1 month of endovascular coiling and management of Gurian group C IAs were associated with greater proportions of perioperative death.

Conclusions: Microsurgical management of previously coiled IAs is an effective and safe strategy in well-selected patients. Important factors to consider in the management of these IAs include the size and location of the IA, rupture status at initial presentation, indication for microsurgery, and type and timing of microsurgery.

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来源期刊
Journal of neurosurgery
Journal of neurosurgery 医学-临床神经学
CiteScore
7.20
自引率
7.30%
发文量
1003
审稿时长
1 months
期刊介绍: The Journal of Neurosurgery, Journal of Neurosurgery: Spine, Journal of Neurosurgery: Pediatrics, and Neurosurgical Focus are devoted to the publication of original works relating primarily to neurosurgery, including studies in clinical neurophysiology, organic neurology, ophthalmology, radiology, pathology, and molecular biology. The Editors and Editorial Boards encourage submission of clinical and laboratory studies. Other manuscripts accepted for review include technical notes on instruments or equipment that are innovative or useful to clinicians and researchers in the field of neuroscience; papers describing unusual cases; manuscripts on historical persons or events related to neurosurgery; and in Neurosurgical Focus, occasional reviews. Letters to the Editor commenting on articles recently published in the Journal of Neurosurgery, Journal of Neurosurgery: Spine, and Journal of Neurosurgery: Pediatrics are welcome.
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