Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes

Abstract

OBJECT While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (< 3 days of SAH). METHODS During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n = 423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n = 442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n = 280) in Period A and Group B (n = 296) in Period B and then compared. RESULTS During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p = 0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0–3) at 1 month (87.9% vs 79.7%, respectively; p = 0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p = 0.018) and better clinical outcomes (1-month mRS score of 0–3: 93.8% vs 87.7%, respectively; p = 0.021) than the patients with good WFNS grades in Group B. CONCLUSIONS Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.

MRI Characterization in the Acute Phase of Experimental Subarachnoid Hemorrhage

“…Imaging in the acute phase of SAH presentation may lead to better delineation of the early brain injury caused by SAH. However, MRI is usually not used in the acute phase of SAH as patients require critical care monitoring and MRI requires longer imaging time with minimal clinical monitoring (39, 40). …”

Predictive Factors for Rebleeding After Aneurysmal Subarachnoid Hemorrhage

“…Of interest, in a recently published large retrospective comparative cohort study (n=1224), Park et al 29 clearly showed that emergency treatment (median time from admission to start of aneurysm repair 3 hours) was not only associated with a significantly lower rebleeding rate but also with an improved clinical outcome.…”

Endovascular treatment of ruptured intracranial aneurysms: Indications, techniques and results

“…Because of the estimated risk of recurrence of 4.1% within 24 hours after the initial rupture, ultra-early treatment of a ruptured aneurysm has been proposed [7]. But on the other hand, the advantages of this strategy are controversial [8], particularly in view of the increased risk of complications during procedures performed in the middle of the night, and also because there is currently no consensus on ultra-early treatment.…”