title: An audit of aneurysmal subarachnoid haemorrhage: earlier resuscitation and surgery reduces inpatient stay and deaths from rebleeding.
abstract: OBJECTIVE
  To audit the outcome in patients with subarachnoid haemorrhage (SAH) after a change in management strategy.
  
  
  METHODS
  A retrospective analysis of patients with aneurysmal subarachnoid haemorrhage over a 20 month period (phase 1) was followed by a prospective analysis of patients presenting during the next 20 months (phase 2) in which a protocol driven management regime of immediate intravenous fluid resuscitation and earlier surgery was pursued. Patients in this phase were grouped into those receiving early (within four days of subarachnoid haemorrhage) and late (after four days of subarachnoid haemorrhage) surgery. In phase 1, 75 out of a total of 92 patients underwent surgery on (median) day 12. From phase 2, 109 patients out of a total of 129 underwent surgery on (median) day 4, 58 of which had their surgery within 4 days of the subarachnoid haemorrhage. Patients in each phase/group were well matched for demographic features, site of aneurysm, and severity of subarachnoid haemorrhage.
  
  
  RESULTS
  The surgical morbidity and mortality were no different in the two phases (P < 0.92; chi2 test). The management outcomes in the two phases of the study were also no different (P < 0.52). However, there was a significant reduction in the rebleed rate in patients undergoing surgery within four days of the subarachnoid haemorrhage in phase 2 (P < 0.0001) with an associated trend towards reduced incidence of postoperative ischaemia (P = 0.06) and mortality (P = 0.11). Operating earlier in phase 2 of the trial resulted in a lower total hospital inpatient stay of 15.8 (95% CI 13.1-18.5) days for survivors compared with 25.7 (95% CI 21.6-29.8) days in the late group (P < 0.00001; t test).
  
  
  CONCLUSIONS
  surgical morbidity and mortality seemed independent of the timing of aneurysm surgery. Early surgery within four days was associated with a highly significant reduction in rebleed rate, and in the duration of total hospital inpatient stay.
authors.affiliation: University Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: P C
authors.initials: PC
authors.lastname: Whitfield
authors.forename: H
authors.initials: H
authors.lastname: Moss
authors.forename: D
authors.initials: D
authors.lastname: O'Hare
authors.forename: P
authors.initials: P
authors.lastname: Smielewski
authors.forename: J D
authors.initials: JD
authors.lastname: Pickard
authors.forename: P J
authors.initials: PJ
authors.lastname: Kirkpatrick
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015994:Incidence; D002532:Intracranial Aneurysm / Q000150:complications*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000401:mortality* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome