Preventable poor outcome from rebleeding by emergency aneurysm occlusion in patients with aneurysmal subarachnoid haemorrhage

Abstract

Introduction: The risk of rebleeding is highest during the initial hours after aneurysmal subarachnoid haemorrhage (aSAH), but the aneurysm is not occluded in all patients immediately after admission. Our aim was to determine the proportion of aSAH patients with poor outcome from early in-hospital rebleeding that can be prevented by three emergency aneurysm occlusion regimes. Patients and methods: From our prospectively collected database, we retrieved from all aSAH patients admitted between July 2007 and July 2017 data on clinical condition on admission, time of rebleeding, and outcome at 3 months. Results: Of 1391 consecutive aSAH patients, 923 were in good clinical condition and had an aneurysm on initial imaging that was amenable for treatment. Poor outcome from rebleeding could have been avoided by treatment <4 h during day time shifts in 4 (0.4% [95% CI: 0.2-1.1]) patients (number needed to treat [NNT]: 250), by treatment and <1 h during daytime shift in 9 (1.0% [95% CI: 0.5-1.8]; NNT: 111), and treatment <1 h at 24/7 basis in 16 (1.7% [95% CI: 1.1-2.8%]; NNT: 59). Discussion: Emergency aneurysm occlusion can reduce poor outcome due to rebleeding, but only in small proportions of patients. Whether such strategies lead to improved outcome for all patients and are cost-effective is highly uncertain. Conclusion: We do not recommend instalment of a treatment regimen where occlusion of ruptured aneurysm is performed within 1 h on a 24/7 basis.

Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns

“…However, since the risk of rebleeding in patients undergoing early aneurysm occlusion is around 10% to 15%, and strict BP control does not eliminate rebleeding, such an RCT would need to include several thousands of patients, making it an ambitious endeavour. 33,34 Since emergency clipping, that is clipping within the initial hours after admission on a 24/7 basis, has a modest treatment effect, if at all, and its cost-effectiveness is uncertain due to the high burden on resources, 35 a RCT of BP lowering should be a high priority, as it is a promising strategy to improve outcome that could be initiated during the transport of patients by ambulance to an appropriate facility.…”

Efficacy and Safety of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…The current evidence suggests that effective aneurysm treatment as early as possible is the best way to reduce or even to prevent rebleeding after hemorrhage (10)(11)(12). However, not all patients are treated immediately within a few hours after admission (13,14). Therefore, a more effective treatment modality, not just aneurysm surgery alone, is still needed before the aneurysm is secured.…”

Treatment delay from aneurysmal subarachnoid hemorrhage to endovascular treatment: a high-volume hospital experience

“…Thereafter, early treatment of responsible ruptured aneurysms was the basic principles in managing aSAH patients. Early treatment could significantly reduce re-bleeding rate and improve clinical outcomes, especially in poorgrade patients [8][9][10]. Menno et al reported the time interval between initial hemorrhage and treatment, with 76% patients treated by coiling or clipping within 24 h after diagnosis [11].…”