Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis
Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis
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DOI：
10.1007/s00701-019-04025-w
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发表时间：
2019-10-01
影响因子：
2.4
通讯作者：
Kirollos, Ramez
中科院分区：
文献类型：
--
作者：
Mohan, Midhun;Islim, Abdurrahman I.;Kirollos, Ramez
自发性蛛网膜下腔出血（SAH）的患者，在最初的检查中并不总是能发现出血的血管原因。本研究旨在系统评价这些病例（通常被描述为“非系统性”SAH（naSAH））的延迟调查策略和临床结局。方法采用PRISMA检查表进行系统评价。采用随机效应模型估计主要结局指标的合并比例。结果共纳入58篇文献（4473例患者）。队列分为中脑周围naSAH（PnaSAH）（49.9%）、非PnaSAH（44.7%）和腰椎穿刺确定的放射学阴性SAH（5.4%）。最常见的初始血管成像方式是数字减影血管造影术。在3.9% [95% CI 1.9-6.6]的延迟研究期间发现血管异常。对于延迟调查的时间或方式没有统一的策略。诊断后3-6个月时改良兰金量表结局（0-2）良好的汇总比例为92.0% [95% CI 86.0-96.5]。并发症包括再出血（3.1% [95% CI 1.5-5.2]）、脑积水（16.0% [95% CI 11.2-21.4]）、血管痉挛（9.6% [95% CI 6.5-13.3]）和癫痫发作（3.5% [95% CI 1.7-5.8]）。根据出血模式分层，我们发现非PnaSAH患者的延迟诊断率较高（13.6% [95%CI 7.4-21.3]），良好功能结局比例较低（87.2% [95%CI 80.1-92.9]），并发症风险较高。结论本研究强调了naSAH患者延迟检查和结局的异质性，这可能受到初始出血模式的影响。需要进一步的多中心前瞻性研究来阐明针对这一异质性患者组的最佳定制管理策略。
Background In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as "non-aneurysmal" SAH (naSAH). Methods A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model. Results Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9-6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0-2) at 3-6 months following diagnosis was 92.0% [95% CI 86.0-96.5]. Complications included re-bleeding (3.1% [95% CI 1.5-5.2]), hydrocephalus (16.0% [95% CI 11.2-21.4]), vasospasm (9.6% [95% CI 6.5-13.3]) and seizure (3.5% [95% CI 1.7-5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4-21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1-92.9]) and higher risk of complications for non-PnaSAH patients. Conclusion This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients.