Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes.
OBJECTIVE
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.
Departments of Neurosurgery and.
Jaechan
J
Park
Hyunjin
H
Woo
Dong-Hun
DH
Kang
Yong-Sun
YS
Kim
Min Young
MY
Kim
Im Hee
IH
Shin
Sang Gyu
SG
Kwak
D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000628:therapy*; D002985:Clinical Protocols; D004621:Embolization, Therapeutic; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D007297:Inpatients; D002532:Intracranial Aneurysm / Q000628:therapy*; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome
ACA = anterior cerebral artery; EACA = ɛ-aminocaproic acid; EVD = external ventricular drainage; ICA = internal carotid artery; IQR = interquartile range; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; VBA = vertebrobasilar artery; WFNS = World Federation of Neurosurgical Societies; emergency treatment; formal protocol; intracranial aneurysm; mRS = modified Rankin Scale; outcome; subarachnoid hemorrhage; vascular disorders