动脉瘤性蛛网膜下腔出血(aSAH)与高死亡率和高发病率相关。我们旨在通过对随机试验进行网络荟萃分析来确定动脉瘤性蛛网膜下腔出血患者的药物预防性治疗的相对益处。
我们搜索了Medline,WebofScience,Embase,Scopus,ProQuest,和CochraneCentral至2020年2月。成对的审稿人独立确定了合格的试验,提取的数据,并评估了偏差的风险。符合条件的试验比较了任何口服或静脉内药物或颅内药物洗脱植入物与彼此或安慰剂或标准护理对确诊为动脉瘤性蛛网膜下腔出血的成年住院患者的预防效果。我们使用了等级(建议评估的等级,开发和评估)评估证据确定性的方法。
我们纳入了53项试验,招募了10415名患者。与安慰剂相比,尼莫地平可能降低全因死亡率(比值比[OR],0.73[95%CI,0.53-1.00];中等确定性;绝对风险降低(ARR),-3.35%)。尼莫地平(或,1.46[95%CI,1.07-1.99];高确定性;绝对风险增加,8.25%)和西洛他唑(OR,3.73[95%CI,1.14-12.18];中等确定性;绝对风险增加,23.15%)是在最长的随访中改善残疾的最有效治疗方法。与安慰剂相比,克拉佐坦(10mg/kg;OR,0.39[95%CI,0.22-0.68];高确定性;ARR,-16.65%),尼卡地平(或,0.48[95%CI,0.24-0.94];中等确定性;ARR,-13.70%),法舒地尔(或,0.55[95%CI,0.31-0.98];中等确定性;ARR,-11.54%),和镁(或,0.66[95%CI,0.46-0.94];高确定性;ARR,-8.37%)被证明对降低迟发性脑缺血的可能性最有效。
尼莫地平和西洛他唑可能是预防动脉瘤性蛛网膜下腔出血患者发病率和死亡率最有效的治疗方法。Clazosentan,尼卡地平,法舒地尔,镁对迟发性脑缺血和血管痉挛具有有益作用,但未发现它们能降低死亡率或致残率。未来的试验有必要仔细研究可能改善死亡率和长期功能结局的药物的预防作用。如西洛他唑和克拉唑生坦。
URL:https://www。crd.约克。AC.uk/PROSPERO/;唯一标识符:CRD42019122183。
Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials.
We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence.
We included 53 trials enrolling 10 415 patients.
Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%).
Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia.
Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan.
URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.