Ebs sah 2012

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Poor grade aneurysmal subarachnoid haemorrhage:

to rush or not to rush?

Macquarie Neurosurgery

Evidence Based Surgery presentation

22 March 2012

D. Bervini

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• Dilemma: “can early surgery for poor grade patients be undertaken to reduce the risk of rebleeding without causing a significant deterioration in overall management outcome by inflicting excess morbidity and mortality?”

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Searchable question

• “Does early surgery for patients with poor grade aneurysmal subarachnoidal haemorrhage improve outcome (compared to delayed surgery)?”

• Databases

• Ovid Medline, usingMeSH

• Scopus using key articles and tracking citations

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Searchable question (PICO format)• Population: patients with poor grade

aneurysmal subarachnoid hemorrhage

• Intervention: early surgery

• Compared: delayed surgery (or conservative treatment)

• Outcome: outcome (morbidity and mortality)

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Search strategy

http://libguides.mq.edu.au/content.php?pid=167579&sid=1412020

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Search strategy

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SCOPUS

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Author Article Journal No Mortality Favorable outcome

Jian-Wei Pan 2009Ultra-Early Surgery for Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage Yonsei Med J 9 22% 44%

Zentner J 1996Results of early surgery in poor-grade aneurysm patients

Journal of Neurosurgical Sciences 85 29%

52% (HH IV) 22% (HH V)

Steudel, W.-I 1994Modulated surgery in the management of ruptured intracranial aneurysm in poor grade patients Neurological Research 116 23% 56%

Spetzger, U. 1994Results of early aneurysm surgery in poor-grade patients Neurological Research 76 28% 54%

Seifert, V. 1990

Management morbidity and mortality in grade IV and V patients with aneurysmal subarachnoid haemorrhage Acta Neurochirurgica 74 31% (HH IV) 53% (HH IV)

Bailes JE 1990Management morbidity and mortality of poor-grade aneurysm patients. J Neurosurg 34 23% 54%

G. Rordorf 1997

Patients in Poor Neurological Condition after Subarachnoid Hemorrhage: Early Management and Long-Term Outcome Acta Neurochirurgica 118 30% 47%

Julian E. B 1990Management morbidity and mortality of poor-grade aneurysm patients Neurosurg 35 23% 65%

John D. Laidlaw 2002

Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not J Neurosurg 177 45% 40%

Ungersbo Jck et al 1994Aneurysm surgery of patients in poor condition. Indications and experience. Neurol Res 27 22% 11%

Steudel et al 1994Modulated surgery in the management of ruptured intracranial aneurysm in poor grade patients Neurol Res 57 23% 56%

Bryan J. Duke 1998Outcome after Urgent Surgery for Grade IV Subarachnoid Hemorrhage Surg Neurol 27 33% 59%

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Summary of papers

• National Health and Medical Research Council (NHMRC) Evidence Hierarchy

- All articles Level III

(no randomised controlled trials or review)

- No randomized study for poor grade SAH

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- Observational retrospective case series

- HH IV and V before and after EVD- All patients except those who showed CT scan evidence of destruction of critical areas had EVD- 97 surgery, 26 endovascular, <24h- Mortality 30% for treatment (100% for no surgery)- Outcome 1y: 47% good outcome after treatment

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- Cohort study- HH IV-V- 35 Pt surgery

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- Cohort study- All neurological grade included (except brain dead), with 45% (177) WFNS IV and V- Rebleeding higher in the first 24h ultra-early surgery (<24h)- DVE only if acute hydrocephalus on CT- 133 Pt with poor grade went ultra-early surgery- 3-12m follow-up

- good outcome 40%, mortality 45% for poor grade- rebleeding not an argument against early surgery (mean 12%, 20% rebleed for WFNS IV and V), only 11% have poor outcome- no debate between surgery and endovascular ttt

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• Early surgery for HH I-III:– 90% good neurological recovery range– Mortality 1.7-8%

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• Rebleeding maximal in the first 24 h (4%)

• Second haemorrhage increases mortality to approximately 70%

•

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Conclusions

No randomised studies for early vs delayed surgery

sound evidence on the best timing of surgery regarding mortality and morbidity is still lacking

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Indirect comparison between different cohorts of patients suggests that early surgery improves outcome ( mortality > morbidity) after aneurysmal SAH in patient with poor clinical conditions at admission compared to delayed surgery.

Each patient must be individually assessedIntracerebral blood clot?Surgical challange in hostile conditions?Endovascular treatment?General medical conditions?Neurological and radiological deep brain lesions?Age?……

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Thank you