Prophylactic magnesium sulfate for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

Delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage is a cause of considerable morbidity and mortality. Magnesium sulfate has been proposed as a prophylactic intervention for angiographic vasospasm and to improve clinical outcomes. A systematic review was conducted to determine the evidence for the prophylactic use of magnesium sulfate in aneurysmal subarachnoid hemorrhage. Medline, Embase, Cochrane library, clinicaltrials.gov, and controlled-trials.com were searched with a comprehensive search strategy. 2,035 records were identified in the initial search and 1,574 remained after removal of duplicates. Randomized, parallel group, controlled trials of magnesium sulfate in patients with aneurysmal subarachnoid hemorrhage were included. A total of ten studies were included. Review Manager and GRADE software were used to synthesize the results. The summary effect for Glasgow outcome scale and the modified Rankin scale is a risk ratio (RR) of 0.93 [95 % confidence interval (CI) 0.82-1.06]. The RR for mortality is 0.95 [95 % CI 0.76-1.17]. Delayed cerebral ischemia has a RR of 0.54 [95 % CI 0.38-0.75], which is the only outcome with a statistically significant summary effect measure favoring magnesium treatment. Delayed ischemic neurological deficit has a RR of 0.93 [95 % CI 0.62-1.39]. Transcranial doppler vasospasm has a RR of 0.72 [95 % CI 0.51-1.03]. Current evidence does not support the prophylactic use of magnesium sulfate in aneurysmal subarachnoid hemorrhage.

Effect of socioeconomic status on inpatient mortality and use of postacute care after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Studies in the United States and Canada have demonstrated socioeconomic gradients in outcomes of acute life-threatening cardiovascular and cerebrovascular diseases. The extent to which these findings are applicable to subarachnoid hemorrhage is uncertain. This study investigated socioeconomic status-related differences in risk of inpatient mortality and use of institutional postacute care after subarachnoid hemorrhage in the United States and Canada. METHODS: Subarachnoid hemorrhage patient records in the US Nationwide Inpatient Sample database (2005-2010) and the Canadian Discharge Abstract Database (2004-2010) were analyzed separately, and summative results were compared. Both databases are nationally representative and contain relevant sociodemographic, diagnostic, procedural, and administrative information. We determined socioeconomic status on the basis of estimated median household income of residents for patient's ZIP or postal code. Multinomial logistic regression models were fitted with adjustment for relevant confounding covariates. RESULTS: The cohort consisted of 31,631 US patients and 16,531 Canadian patients. Mean age (58 years) and crude inpatient mortality rates (22%) were similar in both countries. A significant income-mortality association was observed among US patients (odds ratio, 0.77; 95% CI, 0.65-0.93), which was absent among Canadian patients (odds ratio, 0.97; 95% CI, 0.85-1.12). Neighborhood income status was not significantly associated with use of postacute care in the 2 countries. CONCLUSIONS: Socioeconomic status is associated with subarachnoid hemorrhage inpatient mortality risk in the United States, but not in Canada, although it does not influence the pattern of use of institutional care among survivors in both countries.

Tuberculum sellae meningiomas: a systematic review of transcranial approaches in the endoscopic era.

INTRODUCTION: With the advent of skull base endoscopy, tuberculum sellae meningiomas (TSMs) are currently operated both from the traditional transcranial (TC) route as well as the extended endonasal endoscopic trasns-sphenoidal approach (EETS). The aim of this study was to conduct a systematic review of TSMs excised via the TC route in the modern era when the EETS excision is gaining popularity. EVIDENCE ACQUISITION: We performed a systematic review in the medical literature following the PRISMA guidelines. A medical librarian retrieved a list of 3443 articles published from 2006-2016 from the Medline, Embase and Cochrane Central databases. Two of the authors independently screened for titles and abstracts and excluded 3340 of them. We reviewed the full text of the remaining 103 articles and included in our analysis 31 that met the following inclusion criteria: 1) 5 or more cases reported; and 2) report of the extent of resection, visual outcomes and complications specifically for TSMs were documented. EVIDENCE SYNTHESIS: Thirty-one articles were selected for this systematic review with a total number of 983 patients with TSM. The mean age was 54.1±4.6 years, 75% of them being female. The follow-up was 43.9±20.7 months. The mean tumor diameter was 27.8±4.9 mm. Gross total resection was achieved in 84% while subtotal or near total resection was 14%. Vision improved, worsened and remained unchanged in 65.5%, 10.4%, and 24.7% respectively. The CSF leak rate was 3.4%. Transient or permanent pituitary dysfunction was reported in 6.9% of patients. There was a vascular injury in 5.1% of the patients with the majority (4.3%) being symptomatic. The recurrence rate was 3.8% and mortality 1.1%. CONCLUSIONS: In the past decade, the ETTS excision of TSMs has gained popularity and in some centers has become the approach of choice. However the TC route still remains the most common approach for most TSMs meningiomas and for the majority of neurosurgeons. The evolution of transcranial surgery including the use of minimally invasive techniques, such as endoscope-assisted transcranial resection are associated with relatively high resection rates and improved visual outcomes with low morbidity and mortality. A direct comparison with TS approaches was not done for the purpose of this review analysis. Given the limited availability and heterogeneity of comparative observational studies, a meta-analysis was deemed inappropriate.

Endonasal endoscopic transsphenoidal excision of tuberculum sellae meningiomas: a systematic review.

INTRODUCTION: The endonasal endoscopic approach (EEA) for the resection of tuberculum sellae meningiomas (TSMs) has, more recently, been advocated as an alternative approach to deal with this challenging tumor. The aim of this study was to conduct a systematic review of publications of TSMs excised through the transsphenoidal route in the past 10 years and review data on the extent of excision, visual outcomes and complication rates. EVIDENCE ACQUISITION: We performed a thorough systematic review of the medical literature following the PRISMA guidelines. A medical librarian retrieved a list of 3443 articles published from 2006-2015 from the MEDLINE, EMBASE and Cochrane Central databases. Two of the authors independently screened for titles and abstracts and excluded 3340 of them. We reviewed the full text of the remaining 103 articles and included in our analysis 12 that met the following inclusion criteria: 1) 5 or more cases reported; 2) the extent of resection, visual outcomes and complication rates that were specifically documented for TSMs excised through the transsphenoidal route. EVIDENCE SYNTHESIS: Twelve studies that included 150 patients were analyzed. The mean age was 55 years. The mean tumor volume, reported in 2 studies, was 6.6 cc and mean maximum diameter, reported in 11 studies, was 25 mm. The gross total resection rate was 77.2%. Vision improved in 79.5% of cases and deteriorated in 7.3%. CSF leak postoperatively occurred in 15.3% of patients. In the 11 studies that reported hormonal outcomes, there was a 9.4% transient hyponatremia or diabetes insipidus and 2.2% of patients developed a new permanent endocrine dysfunction. A symptomatic vascular injury was reported in 2.6% of patients. There was one mortality (0.6%). CONCLUSIONS: The endonasal endoscopic transsphenoidal excision of TSMs is a feasible, safe and effective surgical option with a low morbidity and mortality. The use of this approach has evolved in the last 10 years and in some centers has replaced the transcranial route for selected cases. Given the limited availability and heterogeneity of comparative observational studies, a direct comparison with transcranial approaches was not performed for the purpose of this review analysis. Likewise, from an epidemiological and statistical perspective a meta-analysis was deemed inappropriate.

Predictors of seizure outcomes in children with tuberous sclerosis complex and intractable epilepsy undergoing resective epilepsy surgery: an individual participant data meta-analysis.

OBJECTIVE: To perform a systematic review and individual participant data meta-analysis to identify preoperative factors associated with a good seizure outcome in children with Tuberous Sclerosis Complex undergoing resective epilepsy surgery. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science), archives of major epilepsy and neurosurgery meetings, and bibliographies of relevant articles, with no language or date restrictions. STUDY SELECTION: We included case-control or cohort studies of consecutive participants undergoing resective epilepsy surgery that reported seizure outcomes. We performed title and abstract and full text screening independently and in duplicate. We resolved disagreements through discussion. DATA EXTRACTION: One author performed data extraction which was verified by a second author using predefined data fields including study quality assessment using a risk of bias instrument we developed. We recorded all preoperative factors that may plausibly predict seizure outcomes. DATA SYNTHESIS: To identify predictors of a good seizure outcome (i.e. Engel Class I or II) we used logistic regression adjusting for length of follow-up for each preoperative variable. RESULTS: Of 9863 citations, 20 articles reporting on 181 participants were eligible. Good seizure outcomes were observed in 126 (69%) participants (Engel Class I: 102(56%); Engel class II: 24(13%)). In univariable analyses, absence of generalized seizure semiology (OR = 3.1, 95%CI = 1.2-8.2, p = 0.022), no or mild developmental delay (OR = 7.3, 95%CI = 2.1-24.7, p = 0.001), unifocal ictal scalp electroencephalographic (EEG) abnormality (OR = 3.2, 95%CI = 1.4-7.6, p = 0.008) and EEG/Magnetic resonance imaging concordance (OR = 4.9, 95%CI = 1.8-13.5, p = 0.002) were associated with a good postoperative seizure outcome. CONCLUSIONS: Small retrospective cohort studies are inherently prone to bias, some of which are overcome using individual participant data. The best available evidence suggests four preoperative factors predictive of good seizure outcomes following resective epilepsy surgery. Large long-term prospective multicenter observational studies are required to further evaluate the risk factors identified in this review.