title: Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day.
abstract: OBJECTIVE
  To systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid haemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality.
  
  
  METHODS
  We searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I2index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias.
  
  
  RESULTS
  16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I2=0%)) but not when compared with treatment at 1-3 days (OR=1.16 (95% CI 0.47 to 2.90; I2=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I2=73%; OR=0.71 (95% CI 0.36 to 1.37; I2=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I2=34%) for treatment <1 day vs days 1-3; OR=1.71 (95% CI 0.72 to 4.03; I2=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I2=48%) for treatment <3 days vs later).
  
  
  CONCLUSIONS
  In only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients.
authors.affiliation: Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sapna
authors.identifier: http://orcid.org/0000-0002-2462-9677
authors.initials: S
authors.lastname: Rawal
authors.affiliation: Division of Neuroradiology, Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Paula
authors.initials: P
authors.lastname: Alcaide-Leon
authors.affiliation: Division of Neurosurgery, Department of Surgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.
authors.forename: R Loch
authors.initials: RL
authors.lastname: Macdonald
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands.
authors.forename: Gabriel J E
authors.identifier: http://orcid.org/0000-0001-8930-3953
authors.initials: GJ
authors.lastname: Rinkel
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: J Charles
authors.initials: JC
authors.lastname: Victor
authors.affiliation: Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Timo
authors.initials: T
authors.lastname: Krings
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Division of General Internal Medicine, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.
authors.forename: Moira K
authors.initials: MK
authors.lastname: Kapral
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.|Department of Medicine, St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis
mesh_terms: D055317:Evidence-Based Practice / Q000592:standards; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome