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

Clinical article

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Object

The 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 Earlier practices of delayed surgery that were intended to avoid less favorable surgical conditions have been replaced by a trend toward early surgery to minimize the risks associated with rebleeding and vasospasm.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.

Methods

Data 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.

Results

Patients 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.

Conclusions

Early 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.

Abbreviations used in this paper: DIND = delayed ischemic neurological deficit; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; IHAST = Intraoperative Hypothermia for Aneurysm Surgery Trial; NIHSS = National Institutes of Health Stroke Scale; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies.

Article Information

Address correspondence to: Kelly Mahaney, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52245. email: kelly-mahaney@uiowa.edu.

Please include this information when citing this paper: published online January 21, 2011; DOI: 10.3171/2010.11.JNS10795.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graph demonstrating percentage of patients with good outcome (GOS 1) as varied by timing of surgery (days).

  • View in gallery

    Graph demonstrating percentage of patients with good outcome (GOS 1) as varied by presence or absence of hydrocephalus on admission head CT scans and timing of surgery (days). Dagger and double dagger denote p values calculated from GOS score × time of surgery within each subgroup of patients; those without and those with hydrocephalus.

  • View in gallery

    Graph demonstrating percentage of patients with good outcome (GOS 1) as varied by Fisher grade (determined on admission head CT scan) and timing of surgery (days). One double dagger and two double daggers denote p values calculated from GOS score × time of surgery within each subgroup of patients; those with Fisher Grades 1 and 2 and those with Fisher Grades 3 and 4.

  • View in gallery

    Multivariate logistic regression analysis; graph demonstrates odds ratio for poor outcome according to timing of surgery (days), with a reference group interval to surgery of 0–1 days, adjusting for standard and additional covariates. Double daggers indicate p < 0.05.

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