Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery

Abstract

Objective-To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. Methods-A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. Results-The proportion of patients that was operated on early-that is, within three days after SAH-was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. Conclusions-In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome. (J Neurol Neurosurg Psychiatry 1997;63:490-493) Keywords: aneurysmal subarachnoid haemorrhage; timing of surgery; rebleeding Rebleeding in the first three weeks after aneurysmal subarachnoid haemorrhage (SAH) is a very frequent and severe complication. Without operative intervention and without antifibrinolytic treatment about 30% of the patients have a rebleed within one month of the initial SAH.1 In a series of patients with a rebleed established by CT about 50% progressively deteriorated and died from the rebleed and 30% died from other complications. Only 20% of the patients with a rebleed survived at three months and most had severe brain damage.

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

“…Most studies recording outcomes associated with ultra-early rebleeding have demonstrated incidences of Ͼ10% and case-fatality rates approaching 65%, some as high as 80%. [3][4][5][6][7][8][9][10]21,41 The evidence for securing ruptured aneurysms with neurosurgical clipping or endovascular coiling to prevent rebleeding is sound, and there is evidence from the International Subarachnoid Hemorrhage Trial that endovascular coiling is the preferred method when both techniques are equally suited. 21,[31][32][33][34][42][43][44][45][46][47] Logically, therefore, it follows that securing the aneurysm with endovascular coiling or neurosurgical clipping in the for the ultra-early (coiling within 24 hours of SAH) and not ultra-early (coiling at Ͼ24 hours post-SAH) groups.…”

“…Earlier treatment of the ruptured aneurysm lowers the incidence of rebleeding but was historically regarded as a higher risk than a delayed procedure. [1][2][3][4][5][6][7][8][9][10][11] The literature to date on treatment timing has debated and documented the shift from advocacy of late surgery, defined as Ͼ10 days postsubarachnoid hemorrhage (SAH), to "early" surgery, defined as 1 to 3 days post-SAH. Studies analyzing so-called "ultra-early" aneurysm treatment, within 24 hours of SAH, are few in number.…”

Timing of Aneurysm Treatment After Subarachnoid Hemorrhage

“…1,2 To prevent rebleeding, treatment of the ruptured aneurysm was almost exclusively performed by neurosurgical clipping before 1995. Over many years, there has been debate about the most suitable timing of surgery.…”

Hemorragia subaracnoidea aneurismática: guía de tratamiento del Grupo de Patología Vascular de la Sociedad Española de Neurocirugía

“…Hasta hoy día, la cirugía se ha considerado el tratamiento de elección en la HSA, si bien en el mejor de los casos (referencia inmediata, cirugía precoz), sólo se podrían llegar a operar alrededor del 60% de los pacientes con aneurismas 64 ; aunque es difícil comparar los resultados de las distintas series publicadas en la literatura, ya que incluyen poblaciones muy diferentes, por lo tanto, las cifras de mortalidad serán muy diferentes si el estudio es poblacional, hospitalario o si sólo incluye a los pacientes operados 68,89,101,147,223 . Siempre ha existido una controversia sobre cuál es el mejor momento para intervenir a un paciente con HSA 45,51,85,112,113,143,157,165,180,182,187,193,224 . Hasta la fecha sólo existen dos estudios prospectivos, randomizados 88,165 que demuestren el beneficio de la cirugía precoz (0-3 días) respecto a la tardía(>7-10 días).…”