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. 2020 May 18;12(5):e8187.
doi: 10.7759/cureus.8187.

Patient Outcomes With Use of Computed Tomography Angiography in Acute Ischemic Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis

Siying Shari Li  1 , Aleksandar Trajkovski  2 , Michael Siarkowski  3   4 , Calvin Santiago  5 , Kevin A Eng  6 , Teruko Kishibe  7 , Athithyan Umakanthan  8 , Eddy Lang  9
Affiliations

Patient Outcomes With Use of Computed Tomography Angiography in Acute Ischemic Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis

Siying Shari Li et al. Cureus. .

Abstract

Objectives It remains uncertain whether computed tomography angiography (CTA) in ischemic strokes and transient ischemic attacks (TIAs) benefits patient outcomes beyond those eligible for endovascular therapy. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) investigating the use of CTA against other imaging modalities for recurrent stroke, mortality, disability, emergency department (ED) revisits, or changes in management in ischemic stroke and TIA. (PROSPERO: 349590) Methods MEDLINE, Embase, and CENTRAL were searched. We included studies evaluating CTA against non-CTA imaging modalities for outcomes of interest in ischemic stroke or TIA. Two reviewers extracted data and assessed study quality. Data were pooled by the generic inverse variance method. Heterogeneity was assessed using Cochran's Q statistic and quantified by I2. Quality of the evidence was assessed by GRADE. Results We found 12 eligible cohort studies involving 17,481 patients, and no eligible RCTs. No changes were detected in recurrent stroke, mortality, or disability when CTA was compared against pooled imaging modalities, nor compared to non-contrast computed tomography (NCCT) alone. The evidence for each outcome was graded as low quality to very low quality. Conclusions CTA use was not associated with significant reductions in recurrent stroke, mortality, or disability in ischemic stroke and TIA patient compared with other imaging modalities. More high-quality studies are needed.

Keywords: computed tomography angiography; ct angiography; cta; ischemic stroke; stroke; tia; transient ischemic attack.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. PRISMA Search Summary
*We attempted to contact authors for all studies with insufficient data (e.g., conference abstracts). The ones for which we were unable to retrieve further data were ultimately excluded.
Figure 2
Figure 2. CTA vs NCCT for Recurrent Stroke Forest Plot
The pooled effect estimates (diamonds) are shown for studies in minor stroke/TIA patients and the total. There were no studies in major stroke. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 3
Figure 3. CTA vs non-CTA for Recurrent Stroke Forest Plot
The pooled effect estimates (diamonds) are shown for studies in minor stroke/TIA patients and the total. There were no studies in major stroke. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attacks.
Figure 4
Figure 4. CTA vs NCCT for Mortality Forest Plot
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography.
Figure 5
Figure 5. CTA vs non-CTA for Mortality Forest Plot
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 6
Figure 6. CTA vs NCCT for Disability Forest Plot
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 7
Figure 7. CTA vs non-CTA for Disability Forest Plot
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 8
Figure 8. Recurrent Stroke for CTA vs NCCT, in-hospital outcomes sensitivity analysis
The pooled effect estimates (diamonds) are shown for studies in major stroke patients and the total. There were no studies in minor stroke/TIA. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 9
Figure 9. Recurrent Stroke for CTA vs NCCT, combined outcomes sensitivity analysis
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients (sICH), minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 10
Figure 10. Recurrent Stroke for CTA vs non-CTA, in-hospital outcomes sensitivity analysis
The pooled effect estimates (diamonds) are shown for studies in major stroke patients and the total. There were no studies in minor stroke/TIA. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 11
Figure 11. Recurrent Stroke for CTA vs non-CTA, combined outcomes sensitivity analysis
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients (sICH), minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 12
Figure 12. Mortality for CTA vs NCCT, in-hospital outcomes
The pooled effect estimates (diamonds) are shown for studies in major stroke patients and the total. There were no studies in minor stroke/TIA. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 13
Figure 13. Mortality for CTA vs NCCT, long-term outcomes
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 14
Figure 14. Mortality for CTA vs non-CTA, in-hospital outcomes
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 15
Figure 15. Mortality for CTA vs non-CTA, long-term outcomes
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 16
Figure 16. Disability for CTA vs NCCT, in-hospital outcomes
The pooled effect estimates (diamonds) are shown for studies in major stroke patients and the total. There were no studies in minor stroke/TIA. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 17
Figure 17. Disability for CTA vs NCCT, long-term outcomes
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; NCCT: Non-contrast computed tomography; TIA: Transient ischemic attack.
Figure 18
Figure 18. Disability for CTA vs non-CTA, in-hospital outcomes
The pooled effect estimates (diamonds) are shown for studies in major stroke patients and the total. There were no studies in minor stroke/TIA. Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
Figure 19
Figure 19. Disability for CTA vs non-CTA, long-term outcomes
Three pooled effect estimates (diamonds) are shown: one each for studies in major stroke patients, minor stroke/TIA patients, and their combination (total). Data are expressed as risk ratios with 95% confidence intervals, using generic inverse-variance random-effects models. Interstudy heterogeneity was tested using the Cochran Q statistic (chi-square) at a significance level of P < 0.10 and quantified using the I2 statistic. CTA: Computed tomography angiography; TIA: Transient ischemic attack.
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References

    1. Increasing use of computed tomographic perfusion and computed tomographic angiograms in acute ischemic stroke from 2006 to 2010. Vagal A, Meganathan K, Kleindorfer DO, Adeoye O, Hornung R, Khatri P. Stroke. 2014;45:1029–1034. - PubMed
    1. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th Edition, Update 2018. Boulanger J, Lindsay M, Gubitz G, et al. Int J Stroke. 2018;13:949–984. - PubMed
    1. Canadian stroke best practice recommendations: hyperacute stroke care guidelines, update 2015. Casaubon LK, Boulanger J-M, Blacquiere D, et al. Int J Stroke. 2015;10:924–940. - PubMed
    1. Clinical policy: critical issues in the evaluation of adult patients with suspected transient ischemic attack in the emergency department. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Suspected Transient Ischemic Attack; Lo BM, Carpenter CR, Hatten BW, Wright BJ, Brown MD. Ann Emerg Med. 2016;68:354–370. - PubMed
    1. Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. Wintermark M, Sanelli PC, Albers GW, et al. Am J Neuroradiol. 2013;34:117–127. - PMC - PubMed

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