Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Abstract

Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre.

Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome.

Results 343 patients who were submitted to surgical clipping in the first 72 hours post-ictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Good-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge and at 6 months. Poor-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge.

Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

Resumo

Objetivos O timing de tratamento dos aneurismas intracranianos rotos tem sido objeto de debate considerável, embora os benefícios da cirurgia precoce (até 72 horas após ictus) sejam amplamente aceitos. O objetivo do presente estudo é avaliar o potencial benefício da cirurgia ultra precoce (até 24 horas) sobre a cirurgia precoce nos pacientes tratados por abordagem cirúrgica no Departamento de Neurocirurgia do Centro Hospitalar e Universitário de Coimbra.

Métodos Foi usada uma base de dados de 17 anos de aneurismas intracranianos que sofreram rotura e que foram tratados cirurgicamente. O resultado foi avaliado pela Escala de Glasgow de desfecho (GOS, na sigla em inglês). As características da população foram analisadas pelo teste de Fisher, qui-quadrado e Mann-Whitney. A regressão logística foi usada para avaliar o impacto do bom estado clínico à admissão (World Federation of Neurological Surgeons [WFNS]) e da cirurgia ultra precoce sobre o bom desfecho (GOS).

Resultados Foram incluídos 343 pacientes submetidos a clipagem cirúrgica nas primeiras 72 horas pós-ictus, 165 dos quais foram submetidos a cirurgia ultra precoce. As características demográficas e pré-operatórias dos pacientes submetidos a cirurgia ultra precoce e precoce foram semelhantes. Pacientes com bom WFNS submetidos a cirurgia ultra precoce demonstraram melhoria do desfecho na alta e aos 6 meses. Os pacientes com WFNS de baixo grau submetidos a cirurgia ultra precoce demonstraram melhoria do desfecho na alta.

Conclusões A cirurgia ultra precoce para pacientes com hemorragia subaracnoidea aneurismática melhora o resultado principalmente em pacientes com bom estado clínico à admissão (WFNS). Esforços devem ser feitos na logística dos departamentos de emergência, a fim de considerar o tratamento nesse período como timing preferencial.

Keywords

aneurysm - early surgery - subarachnoid hemorrhage - ultra-early surgery - neurosurgical clipping

Palavras-chave

aneurisma cerebral - cirurgia precoce - cirurgia ultra precoce - clipagem neurocirúrgica - hemorragia subaracnoideia

Ethical Approval

Ethical approval was obtained from the Coimbra Hospital and University Centre ethical commission.

^* Dr. António Canotilho Lage and Dr. Miguel T. Carvalho contributed equally to this research and should be considered as joint first authors.

• References

• 1 de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery 2002; 50 (02) 336-340 , discussion 340–342
• 2 Solomon RA, Onesti ST, Klebanoff L. Relationship between the timing of aneurysm surgery and the development of delayed cerebral ischemia. J Neurosurg 1991; 75 (01) 56-61
• 3 Kassell NF, Torner JC, Haley Jr EC, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 1990; 73 (01) 18-36
• 4 Kassell NF, Torner JC, Jane JA, Haley Jr EC, Adams HP. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results. J Neurosurg 1990; 73 (01) 37-47
• 5 Gu DQ, Zhang X, Luo B, Long XA, Duan CZ. Impact of ultra-early coiling on clinical outcome after aneurysmal subarachnoid hemorrhage in elderly patients. Acad Radiol 2012; 19 (01) 3-7
• 6 Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg 2002; 97 (02) 250-258 , discussion 247–249
• 7 Laidlaw JD, Siu KH. Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery. Neurosurgery 2003; 53 (06) 1275-1280 , discussion 1280–1282
• 8 Phillips TJ, Dowling RJ, Yan B, Laidlaw JD, Mitchell PJ. Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome?. Stroke 2011; 42 (07) 1936-1945
• 9 Sonig A, Shallwani H, Natarajan SK. , et al. Better outcomes and reduced hospitalization cost are associated with Ultra-Early Treatment of Ruptured Intracranial Aneurysms: A US Nationwide Data Sample Study. Neurosurgery 2018; 82 (04) 497-505 . Doi: 10.1093/neuros/nyx241
• 10 Wong GK, Boet R, Ng SC. , et al. Ultra-early (within 24 hours) aneurysm treatment after subarachnoid hemorrhage. World Neurosurg 2012; 77 (02) 311-315
• 11 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. , et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43 (06) 1711-1737
• 12 Aoyagi N, Hayakawa I. Study on early re-rupture of intracranial aneurysms. Acta Neurochir (Wien) 1996; 138 (01) 12-18
• 13 Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 1996; 84 (01) 35-42
• 14 Hillman J, von Essen C, Leszniewski W, Johansson I. Significance of “ultra-early” rebleeding in subarachnoid hemorrhage. J Neurosurg 1988; 68 (06) 901-907
• 15 Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 1983; 13 (05) 479-481
• 16 Zhao B, Yang H, Zheng K. , et al; AMPAS Study Group. Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 126 (06) 1764-1771
• 17 Zhao B, Zhao Y, Tan X. , et al. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis. BMJ Open 2015; 5 (04) e007410