Timing of Aneurysm Treatment After Subarachnoid Hemorrhage

Abstract

Background and Purpose-The ideal timing of coiling or clipping after aneurysmal subarachnoid hemorrhage is unknown.Within the International Subarachnoid Aneurysm Trial we assessed differences in incidence of delayed cerebral ischemia and clinical outcome between different timings of treatment. Methods-The treated 2106 patients randomized to coiling or clipping were divided into 4 categories: treatment Ͻ2 days, on days 3 to 4, on days 5 to 10, and Ͼ10 days after the hemorrhage. ORs with 95% CI were calculated with logistic regression analysis for delayed cerebral ischemia, poor outcome at 2 months, and 1 year for the different timing categories, with treatment Ͻ2 days as reference. Analyses were performed for all patients, and for coiled and clipped patients separately, and were adjusted for baseline characteristics. Results-Adjusted ORs of delayed cerebral ischemia for treatment on days 5 to 10 were 1.18 (95% CI, 0.91-1.53) for all patients, 1.68 (95% CI, 1.17-2.43) after coiling, and 0.79 (95% CI, 0.54 -1.16) after clipping. ORs for poor outcome at 2 months were 1.16 (95% CI, 0.89 -1.50) for treatment (clipping and coiling combined) at 3 to 4 days, 1.39 (95% CI, 1.08 -1.80) for treatment at 5 to 10 days, and 1.84 (95% CI, 1.36 -2.51) for treatment Ͼ10 days. ORs for coiled and clipped patients separately were in the same range. Results for outcome at 1 year were similar. Conclusions-Our results support the current practice for early aneurysm treatment in subarachnoid hemorrhage patients.The risk for poor outcome was highest when treatment was performed after day 10; postponing treatment in patients who are eligible for treatment between days 5 to 10 after subarachnoid hemorrhage is not recommended. (Stroke. 2012;43: 2126-2129.)

Early Endovascular Treatment of Subarachnoid Hemorrhage

“…Recently, a subanalysis concerning the timing of the intervention in the ISAT population has been reported [16]. Here, 42.30% of patients were treated within the first 2 days, 22.88% in days 3–4, 22.50% in days 5–10 and 12.30% 10 days after the bleeding.…”

“…Patients admitted within the first 72 h from hemorrhage development should be treated immediately, if possible, due to the high risk of rebleeding. On the other hand, patients admitted after 72 h may be treated as soon as possible considering the risk of rebleeding, with the purpose to achieve optimal conditions during the intervention, but a treatment delay after day 10 does not seem to be justified [16,29]. …”

Effect of Intraventricular Hemorrhage on the Surgical Outcome of Ruptured Anterior Communicating Artery Aneurysm

“…Although the early surgery is not agreed by all, it has been recommended by many authors in the previous related studies (26,27). A better surgical outcome decreases the fatal re-bleeding rate, and hospital stay has been stated as the benefits of the early surgery (18,28).…”

Neurosurgery for Cerebral Aneurysms

“…Class I evidence from two randomized studies (Ohman and Heiskanen 1989;Ohman et al 1991) and retrospective outcome analysis of patients enrolled in the International Subarachnoid Aneurysm Trial (ISAT) (Dorhout Mees et al 2012) advocate an early time-point for aneurysm surgery within the first <48 h after rupture. If successful, surgical clipping eliminates the risk of rebleeding, facilitates the hypertensive treatment of symptomatic cerebral vasospasm, and allows the removal of large intracerebral and subarachnoid clots, the latter increasing the likelihood and severity of vasospasm.…”