Abstract

ObjectivesIt 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)MethodsMEDLINE, 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.ResultsWe 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.ConclusionsCTA 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.

Highlights

  • Stroke has a major global burden as a leading cause of mortality and morbidity worldwide

  • No changes were detected in recurrent stroke, mortality, or disability when computed tomography angiography (CTA) was compared against pooled imaging modalities, nor compared to non-contrast computed tomography (NCCT) alone

  • CTA use was not associated with significant reductions in recurrent stroke, mortality, or disability in ischemic stroke and transient ischemic attacks (TIAs) patient compared with other imaging modalities

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Summary

Introduction

Stroke has a major global burden as a leading cause of mortality and morbidity worldwide. Patients with stroke as well as transient ischemic attacks (TIAs) are receiving computed tomographic angiography (CTA) as part of the initial work up [1]. Recent guidelines reflect this trend: the 2018 Canadian Stroke Best Practice Guidelines recommend immediate CTA for acute stroke patients potentially eligible for endovascular therapy with A level evidence; and for very high risk patients presenting within 48 hours of non-disabling stroke or TIA, urgent CTA or magnetic resonance angiography (MRA) is recommended with B level evidence [2]. In the 2015 guidelines, for TIA patients not being considered for endovascular or thrombolytic therapy, CTA was recommended with C level evidence [3].

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