Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2015 ◽  
Vol 78 (2) ◽  
pp. 224-231 ◽  
Author(s):  
Bing Zhao ◽  
Xianxi Tan ◽  
Yuanli Zhao ◽  
Yong Cao ◽  
Jun Wu ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Patient Characteristics ◽  
Early Surgery ◽  
World Federation ◽  
Poor Grade ◽  
Excellent Outcome ◽  
Delayed Surgery ◽  
Fisher Grade ◽  
Middle Cerebral Artery Aneurysms

ABSTRACT BACKGROUND: There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. OBJECTIVE: To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. METHODS: Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. RESULTS: Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. CONCLUSION: Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.

Variation of patient characteristics, management, and outcome with timing of surgery for aneurysmal subarachnoid hemorrhage

2011 ◽  
Vol 114 (4) ◽  
pp. 1045-1053 ◽  
Author(s):  
Kelly B. Mahaney ◽  
Michael M. Todd ◽  
James C. Torner
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Management Practices ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Timing Of Surgery ◽  
Early Surgery ◽  
Outcome Variable ◽  
Optimal Time ◽  
World Federation ◽  
Time Interval ◽  
Fisher Grade

ObjectThe past 30 years have seen a shift in the timing of surgery for aneurysmal subarachnoid hemorrhage (SAH). Earlier practices of delayed surgery that were intended to avoid less favorable surgical conditions have been replaced by a trend toward early surgery to minimize the risks associated with rebleeding and vasospasm. Yet, a consensus as to the optimal timing of surgery has not been reached. The authors hypothesized that earlier surgery, performed using contemporary neurosurgical and neuroanesthesia techniques, would be associated with better outcomes when using contemporary management practices, and sought to define the optimal time interval between SAH and surgery.MethodsData collected as part of the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) were analyzed to investigate the relationship between timing of surgery and outcome at 3 months post-SAH. The IHAST enrolled 1001 patients in 30 neurosurgical centers between February 2000 and April 2003. All patients had a radiographically confirmed SAH, were World Federation of Neurosurgical Societies Grades I–III at the time of surgery, and underwent surgical clipping of the presumed culprit aneurysm within 14 days of the date of hemorrhage. Patients were seen at 90-day follow-up visits. The primary outcome variable was a Glasgow Outcome Scale score of 1 (good outcome). Intergroup differences in baseline, intraoperative, and postoperative variables were compared using the Fisher exact tests. Variables reported as means were compared with ANOVA. Multiple logistic regression was used for multivariate analysis, adjusting for covariates. A p value of less than 0.05 was considered to be significant.ResultsPatients who underwent surgery on Days 1 or 2 (early) or Days 7–14 (late) (Day 0 = date of SAH) fared better than patients who underwent surgery on Days 3–6 (intermediate). Specifically, the worst outcomes were observed in patients who underwent surgery on Days 3 and 4. Patients who had hydrocephalus or Fisher Grade 3 or 4 on admission head CT scans had better outcomes with early surgery than with intermediate or late surgery.ConclusionsEarly surgery, in good-grade patients within 48 hours of SAH, is associated with better outcomes than surgery performed in the 3- to 6-day posthemorrhage interval. Surgical treatment for aneurysmal SAH may be more hazardous during the 3- to 6-day interval, but this should be weighed against the risk of rebleeding.

scholarly journals Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage

2015 ◽  
Vol 123 (3) ◽  
pp. 686-692 ◽  
Author(s):  
Hitoshi Fukuda ◽  
Kosuke Hayashi ◽  
Takafumi Moriya ◽  
Satoru Nakashita ◽  
Benjamin W. Y. Lo ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Multivariable Analysis ◽  
World Federation ◽  
Poor Grade ◽  
Younger Age ◽  
Scale Scores ◽  
Cisternal Irrigation ◽  
Observational Cohort ◽  
Middle Cerebral Artery Aneurysms

OBJECT Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and often presents with a poor initial neurological grade; it is not well studied. The aim of this study was to elucidate outcomes of aneurysmal subarachnoid hemorrhage (SAH) with ISH. METHODS Data for 97 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grade IV or V) were retrospectively analyzed from a single-center, prospective, observational cohort database. Ultra-early surgical clipping, removal of hematoma, external decompression for brain swelling, and prevention of vasospasm by cisternal irrigation with milrinone were combined as an aggressive treatment. Characteristics and clinical courses of SAH with ISH were identified. The authors also evaluated any correlations between poor admission-grade SAH and ISH with good functional outcome. RESULTS Patients with poor admission-grade SAH and with ISH were more likely to have initial cerebral edema (p < 0.001, Mann-Whitney U-test), which significantly resolved overtime (p < 0.001, Mann-Whitney U-test). These patients had a better chance of functional survival (modified Rankin Scale scores of 1–3; OR 5.75; 95% CI 1.36–24.3; p = 0.017) at 6 months after hospital discharge, after adjustment for potential confounders such as younger age and better initial neurological grade by multivariable analysis. CONCLUSIONS ISH predicted good functional recovery from poor-grade aneurysmal SAH.

Is Admission Lipoprotein-Associated Phospholipase A2 a Novel Predictor of Vasospasm and Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage?

Neurosurgery ◽  
2019 ◽  
Vol 86 (1) ◽  
pp. 122-131 ◽  
Author(s):  
Chen-Yu Ding ◽  
Han-Pei Cai ◽  
Hong-Liang Ge ◽  
Liang-Hong Yu ◽  
Yuang-Xiang Lin ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Phospholipase A2 ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Unfavorable Outcome ◽  
World Federation ◽  
Predictive Values ◽  
Poor Grade ◽  
Fisher Grade

Abstract BACKGROUND The relationships between lipoprotein-associated phospholipase A2 (Lp-PLA2) level, vasospasm, and clinical outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) are still unclear. OBJECTIVE To identify the associations between admission Lp-PLA2 and vasospasm following subarachnoid hemorrhage and the clinical outcome of aSAH. METHODS A total of 103 aSAH patients who had Lp-PLA2 level obtained within 24 h postbleeding were included. The relationships between Lp-PLA2 level, vasospasm, and clinical outcome were analyzed. RESULTS Vasospasm was observed in 52 patients (50.49%). Patients with vasospasm had significantly higher Lp-PLA2 level than those without (P &lt; .001). Both modified Fisher grade (P = .014) and Lp-PLA2 level (P &lt; .001) were significant predictors associated with vasospasm. The Z test revealed that power of Lp-PLA2 was significantly higher than that of modified Fisher grade in predicting vasospasm (Z = 2.499, P = .012). At 6-mo follow-up, 44 patients (42.72%) had unfavorable outcome and 36 patients (34.95%) died. The World Federation of Neurosurgical Societies (WFNS) grade and Lp-PLA2 level were both significant predictors associated with 6-mo unfavorable outcome and mortality (all P &lt; .001). The predictive values of Lp-PLA2 for unfavorable outcome and mortality at 6-mo tended to be lower than those of the WFNS grade, but the differences were not statistically significant (P = .366 and 0.115, respectively). Poor-grade patients having Lp-PLA2 &gt; 200 μg/L had significantly worse 6-mo survival rate than poor-grade patients having Lp-PLA2 ≤ 200 μg/L (P = .001). CONCLUSION The Lp-PLA2 might be useful as a novel predictor in aSAH patients. A total of 30 poor-grade patients; those with elevated Lp-PLA2 level have higher risk of 6-mo mortality compared to those without.

scholarly journals A scoring model to predict the prognosis of patients with poor-grade aneurysmal subarachnoid hemorrhage

2020 ◽  
Author(s):  
Jie Shen ◽  
Jianbo Yu ◽  
Sicong Huang ◽  
Rajneesh Mungur ◽  
Kaiyuan Huang ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Poor Prognosis ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
World Federation ◽  
Scoring Model ◽  
Derivation Cohort ◽  
Poor Grade ◽  
Fisher Grade ◽  
Cerebral Herniation

Abstract Background Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as World Federation of Neurosurgical Societies (WFNS) grade IV-V has high rates of disability and mortality. The objective of this research is to prognosticate outcomes of poor-grade aSAH accurately. Methods A total of 147 poor-grade aSAH patients in our center were enrolled. Risk variables identified by multivariate logistic regression were used to devise the scoring model (total score of 0–9 points). The score values were estimated according to β coefficients. A cohort of 68 patients from another institute was used to validate the model. Results Multivariate analysis revealed that modified Fisher grade above II (odds ratio [OR], 2.972; p = 0.034), age ≥ 65 years (OR, 3.534; p = 0.006), conservative treatment (OR, 5.078; p = 0.019), WFNS Grade V (OR, 2.638; p = 0.029), delayed cerebral ischemia (OR, 3.170; p = 0.016), shunt-dependent hydrocephalus (OR, 3.202; p = 0.032) and cerebral herniation (OR, 7.337; p < 0.001) were significant predictors of poor prognosis (modified Rankin Scale [mRS] ≥ 3). By integration of above factors, a scoring system was constructed and divided poor-grade aSAH patients into three categories: low risk (0–1 point), intermediate risk (2–3 points) and high risk (4–9 points), with risk of poor prognosis being 11%, 52% and 87% respectively (P < 0.001). The area under the curve in derivation cohort was 0.844 (p < 0.001; 95% CI, 0.778–0.909). AUC in validation cohort was 0.831 (p < 0.001; 95% CI, 0.732–0.929). Conclusions The new scoring model could improve prognostication of prognosis and help decision-making for subsequent complement treatment.

scholarly journals Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2015 ◽  
Vol 77 (5) ◽  
pp. 786-793 ◽  
Author(s):  
◽  
Carole L. Turner ◽  
Karol Budohoski ◽  
Christopher Smith ◽  
Peter J. Hutchinson ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
White Blood Cells ◽  
Cerebral Injury ◽  
World Federation ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Poor Outcome ◽  
Fisher Grade ◽  
Good Grade

Abstract BACKGROUND: There remains a proportion of patients with unfavorable outcomes after aneurysmal subarachnoid hemorrhage, of particular relevance in those who present with a good clinical grade. A forewarning of those at risk provides an opportunity towards more intensive monitoring, investigation, and prophylactic treatment prior to the clinical manifestation of advancing cerebral injury. OBJECTIVE: To assess whether biochemical markers sampled in the first days after the initial hemorrhage can predict poor outcome. METHODS: All patients recruited to the multicenter Simvastatin in Aneurysmal Hemorrhage Trial (STASH) were included. Baseline biochemical profiles were taken between time of ictus and day 4 post ictus. The t-test compared outcomes, and a backwards stepwise binary logistic regression was used to determine the factors providing independent prediction of an unfavorable outcome. RESULTS: Baseline biochemical data were obtained in approximately 91% of cases from 803 patients. On admission, 73% of patients were good grade (World Federation of Neurological Surgeons grades 1 or 2); however, 84% had a Fisher grade 3 or 4 on computed tomographic scan. For patients presenting with good grade on admission, higher levels of C-reactive protein, glucose, and white blood cells and lower levels of hematocrit, albumin, and hemoglobin were associated with poor outcome at discharge. C-reactive protein was found to be an independent predictor of outcome for patients presenting in good grade. CONCLUSION: Early recording of C-reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome.

THERAPEUTIC HYPOTHERMIA IN PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE, REFRACTORY INTRACRANIAL HYPERTENSION, OR CEREBRAL VASOSPASM

Neurosurgery ◽  
2009 ◽  
Vol 64 (1) ◽  
pp. 86-93 ◽  
Author(s):  
Martin A. Seule ◽  
Carl Muroi ◽  
Susanne Mink ◽  
Yasuhiro Yonekawa ◽  
Emanuela Keller
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Side Effects ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Cerebral Vasospasm ◽  
Conventional Treatment ◽  
Mild Hypothermia ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Poor Grade ◽  
Fisher Grade

Abstract OBJECTIVE To evaluate the feasibility and safety of mild hypothermia treatment in patients with aneurysmal subarachnoid hemorrhage (SAH) who are experiencing intracranial hypertension and/or cerebral vasospasm (CVS). METHODS Of 441 consecutive patients with SAH, 100 developed elevated intracranial pressure and/or symptomatic CVS refractory to conventional treatment. Hypothermia (33–34°C) was induced and maintained until intracranial pressure normalized, CVS resolved, or severe side effects occurred. RESULTS Thirteen patients were treated with hypothermia alone, and 87 were treated with hypothermia in combination with barbiturate coma. Sixty-six patients experienced poor-grade SAH (Hunt and Hess Grades IV and V) and 92 had Fisher Grade 3 and 4 bleedings. The mean duration of hypothermia was 169 ± 104 hours, with a maximum of 16.4 days. The outcome after 1 year was evaluated in 90 of 100 patients. Thirty-two patients (35.6%) survived with good functional outcome (Glasgow Outcome Scale [GOS] score, 4 and 5), 14 (15.5%) were severely disabled (GOS score, 3), 1 (1.1%) was in a vegetative state (GOS score, 2), and 43 (47.8%) died (GOS score, 1). The most frequent side effects were electrolyte disorders (77%), pneumonia (52%), thrombocytopenia (47%), and septic shock syndrome (40%). Of 93 patients with severe side effects, 6 (6.5%) died as a result of respiratory or multi-organ failure. CONCLUSION Prolonged systemic hypothermia may be considered as a last-resort option for a carefully selected group of SAH patients with intracranial hypertension or CVS resistant to conventional treatment. However, complications associated with hypothermia require elaborate protocols in general intensive care unit management.

scholarly journals Xanthochromia: yellow color is a red flag

QJM ◽  
2021 ◽  
Author(s):  
Takuhiro Hashiyama ◽  
Nobuaki Mori ◽  
Yu Tsuruyama
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Artery Aneurysm ◽  
World Federation ◽  
Anterior Communicating Artery ◽  
Low Grade ◽  
Presenting Symptoms ◽  
Csf Analysis ◽  
Yellow Color ◽  
Fisher Grade

Abstract A 72-year-old previously healthy man consulted in our hospital for persistent moderate headache, accompanied by flexor pain of both thighs and low-grade fever for five days. Although the symptoms were worsened by motion, he noticed the flexor pain was most severe when taking a bow. On physical examination, he was fully alert and oriented to person, place, and time. His body temperature, blood pressure, pulse, and respiratory rate were 37.6 °C, 126/81 mmHg, 67 beats/min, and 16 breaths/min, respectively. His neck was supple. Kernig’s and Brudzinski’s signs were negative. There was a positive jolt accentuation test. No other neurologic findings were remarkable. Head computed tomography (CT) was normal; therefore, a lumbar puncture was performed, following suspicion of meningitis. Cerebrospinal fluid (CSF) analysis revealed 14 cells per microliter (mononucleosis was dominant), protein 185 mg/dL, and glucose 34 mg/dL. The opening pressure was 13 cmH2O. The CSF had an orange-yellow appearance (Figure 1a). This was suggestive of xanthochromia. Contrast-enhanced head CT and head magnetic resonance imaging were performed, and a ruptured anterior communicating artery aneurysm was detected (Figure 1 b). He was diagnosed with aneurysmal subarachnoid hemorrhage (SAH), which was classified as Grade 1 and Group 1, according to the World Federation of Neurological Surgeons subarachnoid hemorrhage grading scale and Fisher grade of cerebral vasospasm risk, respectively. Regarding the presenting symptoms, thigh flexor pain and low-grade fever were symptoms of breakdown of blood products within the CSF, which led to aseptic meningitis, also called meningismus. He was admitted to the intensive care unit for neurological and hemodynamic monitoring. Aneurysm repair with surgical clipping was performed, and after 4 weeks of rehabilitation, he was discharged ambulatory.

Reactive Thrombocytosis in Non-aneurysmal Subarachnoid Hemorrhage

2020 ◽  
Vol 81 (05) ◽  
pp. 412-417
Author(s):  
Daniel Dubinski ◽  
Sae-Yeon Won ◽  
Bedjan Behmanesh ◽  
Nina Brawanski ◽  
Volker Seifert ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
World Federation ◽  
Reactive Thrombocytosis ◽  
Vp Shunt ◽  
Fisher Grade ◽  
The Impact

Abstract Background The role of reactive thrombocytosis in non-aneurysmal subarachnoid hemorrhage (NA-SAH) is largely unexplored to date. Therefore, the impact of a quantitative thrombocyte dynamic in patients with NA-SAH and its clinical relevance were analyzed in the present study. Methods In this retrospective analysis, 113 patients with nontraumatic and NA-SAH treated between 2003 and 2015 at our institution were included. World Federation of Neurosurgical Societies admission status, cerebral vasospasm, delayed infarction, hydrocephalus, need for ventriculoperitoneal (VP) shunt, and Fisher grade were analyzed for their association with reactive thrombocytosis. Results Reactive thrombocytosis was not associated with hydrocephalus (p ≥ 0.05), need for VP shunt implantation (p ≥ 0.05), cerebral vasospasm (p ≥ 0.05), or delayed cerebral ischemia (p ≥ 0.05). Conclusion Our study is the first to investigate the role of thrombocyte dynamics, reactive thrombocytosis, and the clinical course of NA-SAH patients. Our analysis showed no significant impact of thrombocyte count on NA-SAH sequelae.

Assessment of lipoprotein-associated phospholipase A2 level and its changes in the early stages as predictors of delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage

2020 ◽  
Vol 132 (1) ◽  
pp. 62-68 ◽  
Author(s):  
Chen-Yu Ding ◽  
Han-Pei Cai ◽  
Hong-Liang Ge ◽  
Liang-Hong Yu ◽  
Yuan-Xiang Lin ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Phospholipase A2 ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
Enzyme Linked Immunosorbent Assay ◽  
Poor Grade ◽  
Early Stages ◽  
Fisher Grade ◽  
The Relationship

OBJECTIVEThe relationship between lipoprotein-associated phospholipase A2 (Lp-PLA2) and various cardiovascular and cerebrovascular diseases is inconsistent. However, the connection between Lp-PLA2 level and delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. The objective of this study was to investigate the relationships between the Lp-PLA2 levels in the early stages of aSAH and the occurrence of DCI.METHODSThe authors evaluated 114 patients with aSAH who were enrolled into a prospective observational cohort study. Serum Lp-PLA2 level at admission (D0), on the first morning (D1), and on the second morning of hospitalization (D2) were determined using commercial enzyme-linked immunosorbent assay kits. The relationship between Lp-PLA2 levels and DCI was analyzed.RESULTSForty-three patients with aSAH (37.72%) experienced DCI. Mean serum Lp-PLA2 level decreased from 183.06 ± 61.36 μg/L at D0 (D0 vs D1, p = 0.303), to 175.32 ± 51.49 μg/L at D1 and 167.24 ± 54.10 μg/L at D2 (D0 vs D2, p = 0.040). The Lp-PLA2 level changes (D0-D1 and D0-D2) were comparable between patients with and without DCI. Multivariate model analysis revealed Lp-PLA2 level (D0) > 200 μg/L was a more significant factor of DCI compared with Lp-PLA2 (D1) and Lp-PLA2 (D2), and was a strong predictor of DCI (odds ratio [OR] 6.24, 95% confidence interval [CI] 2.05–18.94, p = 0.001) after controlling for World Federation of Neurosurgical Societies (WFNS) grade (OR 3.35, 95% CI 1.18–9.51, p = 0.023) and modified Fisher grade (OR 6.07, 95% CI 2.03–18.14, p = 0.001). WFNS grade (area under the curve [AUC] = 0.792), modified Fisher grade (AUC = 0.731), and Lp-PLA2 level (D0; AUC = 0.710) were all strong predictors of DCI. The predictive powers of WFNS grade, modified Fisher grade, and Lp-PLA2 (D0) were comparable (WFNS grade vs Lp-PLA2: p = 0.233; modified Fisher grade vs Lp-PLA2: p = 0.771). The poor-grade patients with Lp-PLA2 (D0) > 200 μg/L had significantly worse DCI survival rate than poor-grade patients with Lp-PLA2 (D0) ≤ 200 μg/L (p < 0.001).CONCLUSIONSThe serum level of Lp-PLA2 was significantly elevated in patients with DCI, and decreased within the first 2 days after admission. Lp-PLA2 in the early stages of aSAH might be a novel predictive biomarker for the occurrence of DCI.

Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age

2002 ◽  
Vol 97 (2) ◽  
pp. 250-258 ◽  
Author(s):  
John D. Laidlaw ◽  
Kevin H. Siu
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Early Surgery ◽  
World Federation ◽  
Consecutive Series ◽  
Surgical Clipping ◽  
Content Type ◽  
Ruptured Aneurysms ◽  
Unselected Group ◽  
Fine Print

Object. This study was undertaken to determine the outcomes in an unselected group of patients treated with semiurgent surgical clipping of aneurysms following subarachnoid hemorrhage (SAH). Methods. A clinical management outcome audit was conducted to determine outcomes in a group of 391 consecutive patients who were treated with a consistent policy of ultra-early surgery (all patients treated within 24 hours after SAH and 85% of them within 12 hours). All neurological grades were included, with 45% of patients having poor grades (World Federation of Neurosurgical Societies [WFNS] Grades IV and V). Patients were not selected on the basis of age; their ages ranged between 15 and 93 years and 19% were older than 70 years. The series included aneurysms located in both anterior and posterior circulations. Eighty-eight percent of all patients underwent surgery and only 2.5% of the series were selectively withdrawn (by family request) from the prescribed surgical treatment. In patients with good grades (WFNS Grades I–III) the 3-month postoperative outcomes were independence (good outcome) in 84% of cases, dependence (poor outcome) in 8% of cases, and death in 9%. In patients with poor grades the outcomes were independence in 40% of cases, dependence in 15% of cases, and death in 45%. There was a 12% rate of rebleeding with all cases of rebleeding occurring within the first 12 hours after SAH; however, outcomes of independence were achieved in 46% of cases in which rebleeding occurred (43% mortality rate). Rebleeding was more common in patients with poor grades (20% experienced rebleeding, whereas only 5% of patients with good grades experienced rebleeding). Conclusions. The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early re-bleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.

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