Does Treatment of Ruptured Intracranial Aneurysms Within 24 Hours Improve Clinical Outcome?

Phillips, Timothy J; Dowling, Richard; Yan, Bernard; Laidlaw, John D.; Mitchell, Peter

doi:10.1161/strokeaha.110.602888

Cited by 137 publications

(86 citation statements)

References 58 publications

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“…However, for treatment within 24 hours, it has been shown that this timeframe was associated with improved clinical outcomes, although the benefit was more pronounced for coiling than clipping. 34 Moreover, it is unlikely that the risks of acute treatment will accrue in such a way that they outweigh the very high morbidity and mortality rates associated with rebleeding.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis

Boogaarts¹,

Lieshout²,

Amerongen

et al. 2015

JNS

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OBJECT Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated. METHODS The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality. RESULTS Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms. CONCLUSIONS This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors' results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.

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Section: Discussionmentioning

confidence: 99%

“…34 Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. In recent years, several risk factors, such as hypertension and the location and size of the aneurysm, have been shown to be associated with rebleeding.…”

mentioning

confidence: 99%

Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis

Boogaarts¹,

Lieshout²,

Amerongen

et al. 2015

JNS

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“…Subarachnoid hemorrhage (SAH) is frequently associated with significant morbidity and mortality, especially when the diagnosis is missed (1,2). Unfortunately, initial presenting symptoms of this disease are frequently subtle and often overlap with more common and more benign headaches.…”

Section: Introductionmentioning

confidence: 99%

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Meurer

Walsh

Vilke

et al. 2016

The Journal of Emergency Medicine

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, Abstract-Background: Subarachnoid hemorrhage (SAH) is frequently caused by the rupture of an intracranial aneurysmal vessel or arteriovenous malformation, leading to a cascade of events that can result in severe disability or death. When evaluating for this diagnosis, emergency physicians have classically performed a noncontrast computed tomography (NCCT) scan, followed by a lumbar puncture (LP). Recently, however, as CT technology has advanced, many studies have questioned the necessity of the LP in the SAH diagnostic algorithm and have instead advocated for noninvasive techniques, such as NCCT alone or NCCT with CT angiogram (CTA). Objective: The primary goal of this literature search was to determine the appropriate emergency department (ED) management of patients with suspected SAH. Methods: A MEDLINE literature search from October 2008 to June 2015 was performed using the keywords computed tomography AND subarachnoid hemorrhage AND lumbar puncture, while limiting the search to human studies written in the English language. General review articles and single case reports were omitted. Each of the selected articles then underwent a structured review. Results: Ninety-one articles were identified, with 31 papers being considered appropriate for analysis. These studies then underwent a rigorous review from which recommendations were developed. Conclusions: The literature search supports that NCCT followed by CTA is a reasonable approach in the evaluation of ED patients with possible SAH. Ó 2016 Elsevier Inc.

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“…2 Nevertheless, a diagnosis of aneurysmal SAH should never be missed, because early diagnosis and treatment of aneurysmal SAH are associated with better functional outcomes. 3 Common practice for diagnostic evaluation of patients suspected of having SAH is a head CT and a subsequent lumbar puncture for cerebrospinal fluid (CSF) analysis if head CT is negative or inconclusive. 4,5 A recent study suggested that a lumbar puncture is not needed if a thirdgeneration head CT scan performed within 6 hours after headache onset and interpreted by a qualified radiologist excludes the presence of blood in the subarachnoid space.…”

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confidence: 99%

Time-Dependent Test Characteristics of Head Computed Tomography in Patients Suspected of Nontraumatic Subarachnoid Hemorrhage

Backes

Rinkel

Kemperman

et al. 2012

Stroke

118

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Background and Purpose-A recent study suggested that in patients with acute headache suspicious of nontraumatic subarachnoid hemorrhage (SAH), cerebrospinal fluid (CSF) analysis is not needed to rule out SAH if head CT performed Յ6 hours after ictus is negative. Before implementation in daily practice, these results need replication. Therefore, we investigated test characteristics of head CT in patients with a clinical suspicion of SAH. Methods-Patients suspicious of SAH and a normal level of consciousness presenting to our tertiary care hospital between 2005 and 2012 were included. All patients had a head CT interpreted by experienced neuroradiologists and CSF spectrophotometry if head CT was negative or inconclusive. We determined test characteristics with 95% confidence intervals (CI) for nontraumatic SAH of head CT performed Յ6 or Ͼ6 hours after onset of headache. Results-Sensitivity of head CT Յ6 hours after ictus (nϭ137) was 98.5% (95% CI, 92.1%-100%), diagnosing all patients with aneurysmal and perimesencephalic SAH, but not with a cervical arteriovenous malformation. Sensitivity of head CT performed Ͼ6 hours after ictus (nϭ113) was 90.0% (95% CI, 76.3-97.2). After exclusion of patients with an atypical presentation without headache, sensitivity, specificity, negative predictive value, and positive predictive value of head CT Յ6 hours were all 100%. Conclusions-In patients presenting with acute headache and a normal head CT Յ6 hours after ictus, as interpreted by experienced neuroradiologists, there is no added value of CSF analysis. In patients with an atypical presentation without headache and in patients presenting Ͼ6 hours after ictus, CSF analysis is still indicated. (Stroke. 2012;43:2115-2119.)

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Does Treatment of Ruptured Intracranial Aneurysms Within 24 Hours Improve Clinical Outcome?

Cited by 137 publications

References 58 publications

Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis

Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Time-Dependent Test Characteristics of Head Computed Tomography in Patients Suspected of Nontraumatic Subarachnoid Hemorrhage

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