EBS presentation 1

Poor grade aneurysmal subarachnoid haemorrhage:

to rush or not to rush?

Macquarie Neurosurgery

Evidence Based Surgery presentation

22 March 2012

D. Bervini

EBS presentation 2

EBS presentation 3

EBS presentation 4

EBS presentation 5

EBS presentation 6

• 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?”

EBS presentation 7

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

EBS presentation 8

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)

EBS presentation 9

Search strategy

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

EBS presentation 10

Search strategy

EBS presentation 11

EBS presentation 12

EBS presentation 13

EBS presentation 14

EBS presentation 15

EBS presentation 16

EBS presentation 17

EBS presentation 18

EBS presentation 19

EBS presentation 20

EBS presentation 21

EBS presentation 22

EBS presentation 23

EBS presentation 24

SCOPUS

EBS presentation 25

EBS presentation 26

EBS presentation 27

EBS presentation 28

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%

EBS presentation 29

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

EBS presentation 30

- 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

EBS presentation 31

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

EBS presentation 32

- 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

EBS presentation 33

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

EBS presentation 34

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

• Second haemorrhage increases mortality to approximately 70%

•

EBS presentation 35

Conclusions

No randomised studies for early vs delayed surgery

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

EBS presentation 36

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?……

EBS presentation 37

Thank you