Early Endovascular Treatment of Subarachnoid Hemorrhage

Matías‐Guiu, Jordi A.; Serna-Candel, Carmen

doi:10.1159/000346768

Cited by 11 publications

(7 citation statements)

References 61 publications

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“…Early intervention has become the routine in managing patients with aneurysmal SAH. 20-23 While this reduces the risk of re-bleed, pragmatically, immediate management does not allow effective planning of the intervention. Our results indicate that immediate intervention within 24 hours is not associated with significant improvements in morbidity or mortality at 12 months in pSAH patients compared to delayed intervention after 24 hours.…”

Section: Discussionmentioning

confidence: 99%

Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

Gittins

Talbott

Gilani

et al. 2020

Preprint

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Background/Objective: Patients with poor-grade subarachnoid bleed (pSAH, World Federation of Neurosurgeons grades 4-5) often improve their neurocognitive function months after their ictus. However, it is essential to explore the timing of intervention and its impact on long-term outcome. We compared the long-term outcomes between immediate management within 24 hours (IM) and delayed management after 24 hours (DM) in patients following pSAH. Methods: This was a retrospective population-based study, including patients with pSAH who received definitive management between 1st January 2011 and 31st December 2016 in a large tertiary neurocritical care unit. The primary outcome was adjusted odds ratio (OR) of favourable outcome (Glasgow Outcome Scale (GOS) 4-5) for survivors at 12 months following discharge, as measured by the Glasgow Outcome Scale (GOS). The secondary outcomes included adjusted OR of a favourable outcome at discharge, three months and six months following discharge and survival rate at 28 days, three months, six months and 12 months following haemorrhage. Results: 111 patients were included in this study: 53 (48%) received immediate management (IM) and 58 (41%) received delayed management (DM). The mean time delay from referral to intervention was 14.9±5.8 hours in IM patients, compared to 79.6±106.1 hours in DM patients. At 12 months following discharge, the adjusted OR for favourable outcome in IM versus DM patients was 0.96 (CI 0.17, 5.39; p=0.961). At hospital discharge, three months and six months, the adjusted OR for favourable outcome was 3.85 (CI 1.38, 10.73; p=0.010), 1.04 (CI 0.22, 5.00; p=0.956) and 0.98 (CI 0.21, 4.58; p=0.982), respectively. There were no differences in survival rate between the groups at 28 days, three months, six months and 12 months (71.7% in IM group vs 82.8% in DM group at 12 months, p=0.163). Conclusions: IM and DM after pSAH are associated with similar morbidity and mortality at 12 months. Therefore, delaying intervention in poor-grade patients may be a reasonable approach, especially if time is needed to plan the procedure or stabilise the patient adequately.

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Section: Discussionmentioning

confidence: 99%

Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

Gittins

Talbott

Gilani

et al. 2020

Preprint

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show abstract

“…Early intervention has become the routine in managing patients with aneurysmal SAH. [20][21][22][23] While this reduces the risk of re-bleed, pragmatically, IM does not allow effective planning of the intervention. Our results indicate that immediate intervention within 24 h is not associated with significant improvements in morbidity or mortality at 12 months in pSAH patients compared to delayed intervention after 24 h. This is despite the likelihood of a selection bias favouring earlier intervention in patients perceived to have a better prognosis.…”

Section: Discussionmentioning

confidence: 99%

Outcomes following acute poor-grade aneurysmal subarachnoid bleed – Is early definitive treatment better than delayed management?

Gittins

Talbott

Gilani

et al. 2020

Journal of the Intensive Care Society

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Background/objective Patients with poor-grade subarachnoid bleed (World Federation of Neurosurgical Societies grades 4–5) often improve their neurocognitive function months after their ictus. However, it is essential to explore the timing of intervention and its impact on long-term outcome. We compared the long-term outcomes between immediate management within 24 h and delayed management after 24 h in patients following poor-grade subarachnoid bleed. Methods This was a retrospective population-based study, including patients with poor-grade subarachnoid bleed who received definitive management between 1 January 2011 and 31 December 2016 in a large tertiary neurocritical care unit. The primary outcome was adjusted odds ratio of favourable outcome (Glasgow Outcome Scale 4–5) for survivors at 12 months following discharge, as measured by the Glasgow Outcome Scale. The secondary outcomes included adjusted odds ratio of a favourable outcome at discharge, 3 months and 6 months following discharge and survival rate at 28 days, 3 months, 6 months and 12 months following haemorrhage. Results A total of 111 patients were included in this study: 53 (48%) received immediate management and 58 (52%) received delayed management. The mean time delay from referral to intervention was 14.9 ± 5.8 h in immediate management patients, compared to 79.6 ± 106.1 h in delayed management patients. At 12 months following discharge, the adjusted odds ratio for favourable outcome in immediate management versus delayed management patients was 0.96 (confidence interval (CI) = 0.17, 5.39; p = 0.961). At hospital discharge, 3 months and 6 months, the adjusted odds ratio for favourable outcome was 3.85 (CI = 1.38, 10.73; p = 0.010), 1.04 (CI = 0.22, 5.00; p = 0.956) and 0.98 (CI = 0.21, 4.58; p = 0.982), respectively. There were no differences in survival rate between the groups at 28 days, 3 months, 6 months and 12 months (71.7% in immediate management group vs. 82.8% in delayed management group at 12 months, p = 0.163). Conclusions Immediate management and delayed management after poor-grade subarachnoid bleed are associated with similar morbidity and mortality at 12 months. Therefore, delaying intervention in poor-grade patients may be a reasonable approach, especially if time is needed to plan the procedure or stabilise the patient adequately.

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“…Furthermore, many studies included in this paper were carried out in earlier times, whereas growing body of advanced literatures put more emphasis upon early intervention even ultra-early within 24hours. Thus, corresponding bias may exist in this meta-analysis (29).…”

Section: Limitationsmentioning

confidence: 95%

Surgical timing for aneurysmal subarachnoid hemorrhage: a meta-analysis and systematic review

Zhao

Yi²

2015

Turkish Neurosurgery

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dent after surgery (19). Therefore, with the economic burdens of aSAH increasing every year, cost effectiveness and preventative strategies have become much more important.Before the 1970s, it was thought that cerebral edema and cerebral vascular dysregulation after acute aSAH, were associated with early surgery. In order to avoid the unfavorable █ INTRODUCTION A lthough intracranial aneurysmal subarachnoid hemorrhage (aSAH) accounts only for 3% to 4% of all strokes and 4.4% of deaths from stroke (18,50), aSAH is a significant health problem, which within 1 month has a mortality rate of nearly 50%, and many patients become care-depenAIm: Despite great advances in treatment of aneurysmal subarachnoid hemorrhage (aSAH), yet, a consensus as to the most optimal timing of surgery has not been reached. In order to identify the most suitable time of surgery for aSAH, the authors conducted a meta-analysis and systematic review. mATERIAl and mEThODS: PubMed and the Cochrane Library were searched for English-language studies published up to May 2015. Two independent reviewers screened abstracts, reviewed full-text articles and extracted data. Before conducting the metaanalysis, the studies were evaluated for publication bias and heterogeneity. Fixed and random effect models were used to estimate relative risks (RR) and the corresponding 95% confidence intervals (CIs). Subgroup analysis and sensitivity analysis were also performed. RESUlTS:One randomized controlled trial (RCT) and 33 observational studies of 16,793 participants were included in this paper. The overall methodological quality was satisfying. Results after excluding articles inconsistent with our surgery timing definition showed no significant difference for poor outcome, with early vs intermediate treatment (RR 0.86[0.68,1.09]), early vs late (RR 0.99[0.70,1.40]). Subgroup analysis based on age showed that early surgery could obtain more favorable outcomes for death rate, with non-early group as reference when age ≥50 years (RR 0.52[0.29,0.93]). When less than 50 years old, patients could benefit more from early intervention for poor outcome, with intermediate group as reference (RR 0.18[0.04,0.78 ]).CONClUSION: Despite the shortcomings of this study, timing of surgery for aSAH did not put a significant impact on overall surgical outcome. But subgroup analysis indicated a trend with more benefits for early treatment. Given the risks of re-bleeding and inpatient stay, early intervention should be performed as soon as possible. However, more randomized trials with long-term followup are necessary, especially in this era of endovascular coiling.

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Early Endovascular Treatment of Subarachnoid Hemorrhage

Cited by 11 publications

References 61 publications

Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

Outcomes following acute poor-grade aneurysmal subarachnoid bleed – Is early definitive treatment better than delayed management?

Surgical timing for aneurysmal subarachnoid hemorrhage: a meta-analysis and systematic review

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