Abstract
BackgroundOcclusive atherosclerotic disease of the anterior cerebral circulation is one of the most common causes of anterior circulation ischemia and stroke. Treatment options include medical therapies (including antiplatelet use, blood pressure control, lipid reduction, and lifestyle modification) and extracranial-intracranial bypass surgery (such as superficial temporal artery-middle cerebral artery bypass). However, the optimal treatment remains unclear. The objective of this study will be to compare the efficacy of and extracranial-intracranial bypass surgery with that of other medical therapy in adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation.MethodsThis is the study protocol for a systematic review. We will search MEDLINE, EMBASE, Web of Science, and the Cochrane Library (from January 1980 onwards). We will include randomized controlled trials, quasi-experimental studies (non-randomized, interrupted time series), and observational studies (e.g., cohort studies and case-control studies), examining the efficacy of extracranial-intracranial bypass surgery compared to other treatments for adult patients with occlusive atherosclerotic disease of anterior cerebral circulation. Two team members will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The primary outcome will include stroke or death. The secondary outcomes will include intracranial hemorrhage, transient ischemic attack, and myocardial infarction. The study methodological quality (or bias) will be appraised using appropriate tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design, geographical location, or risk of bias).DiscussionThis review will evaluate the evidence on the efficacy of extracranial-intracranial bypass surgery for adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation. We anticipate that our findings will be of interest to patients, their families, caregivers, healthcare professionals, and in making optimal treatment selection. Implications for future clinical and epidemiological research will be discussed.Systematic review registrationPROSPERO CRD42018105513
Highlights
Occlusive atherosclerotic disease of the anterior cerebral circulation is one of the most common causes of anterior circulation ischemia and stroke
Two subsequent randomized controlled trials (RCTs), including the Japanese EC-IC bypass trial (JET) [33] and Carotid and Middle cerebral artery Occlusion Surgery Study (CMOSS) [34, 35] did not show that bypass surgery was superior to best medical therapy (BMT) in terms of stroke prevention
When a metaanalysis was not feasible due to an insufficient number of studies, we provided a narrative description of the study results
Summary
The present protocol has been registered within the PROSPERO database (registration number CRD42018105513) and is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [39] (see checklist in Additional file 1). Participants The study participants will include patients aged 18 years or over and experienced ischemic stroke caused by occlusive atherosclerotic disease (verified by angiography) of the anterior cerebral circulation They should include those who underwent EC-IC bypass surgery or received BMT. We will extract all relevant data of interest from the included studies for comparison, such as (1) study and patients’ characteristics, (2) group by intervention type, (3) detailed information of surgery techniques and medical treatment plan, and (4) primary and secondary outcomes with observation time points. Data synthesis and analysis We will synthetize primary studies to explore heterogeneity descriptively rather than statistically such as structured narratives, summary tables, and measures of treatment effects. We will conduct a subgroup analysis of the following variables if the data were sufficient, such as study design, geographical location, or risk of bias. We will use methods and recommendations described of the Cochrane Handbook for Systematic Reviews of Interventions and the GRADEpro GDT software
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