BACKGROUND Trauma-induced coagulopathy contributes to significant morbidity and mortality in patients who experience trauma-related bleeding. This study aimed to synthesize the evidence supporting the efficacy and safety of preemptive and goal-directed fibrinogen concentrate (FC) in the management of trauma-related hemorrhage. METHODS PubMed, Medline, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform were systematically searched. All trial designs, except individual case reports, which evaluated the preemptive or goal-directed use of FC for trauma-related bleeding/coagulopathy, in patients older than 16 years, were included in the systematic review. For the included randomized controlled trials comparing FC with control, meta-analysis was performed and a risk-of bias-assessment was completed using the Cochrane Methodology and Preferred Reporting Items Systematic Reviews and Meta-analysis guidelines. RESULTS A total of 2,743 studies were identified; 26 were included in the systematic review, and 5 randomized controlled trials (n = 238) were included in the meta-analysis. For the primary outcome of mortality, there was no statistically significant difference between the groups, with 22% and 23.4% in the FC and comparator arms, respectively (risk ratio, 1.00 [95% confidence interval, 0.39 to 2.56]; p = 0.99). In addition, there was no statistical difference between FC and control in packed red blood cell, fresh frozen plasma, or platelet transfusion requirements, and thromboembolic events. Overall, the quality of evidence was graded as low to moderate because of concerns with risk of bias, imprecision, and inconsistency. CONCLUSION Further high-quality, adequately powered studies are needed to assess the impact of FC in trauma, with a focus on administration as early as possible from the point of entry into the trauma system of care. LEVEL OF EVIDENCE Systematic review and Meta-analysis, level II.

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 I 2 . 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.