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

Abstract

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.