Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age

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Abstract
This study was undertaken to determine the outcomes in an unselected group of patients treated with semiurgent surgical clipping of aneurysms following subarachnoid hemorrhage (SAH). A clinical management outcome audit was conducted to determine outcomes in a group of 391 consecutive patients who were treated with a consistent policy of ultra-early surgery (all patients treated within 24 hours after SAH and 85% of them within 12 hours). All neurological grades were included, with 45% of patients having poor grades (World Federation of Neurosurgical Societies [WFNS] Grades IV and V). Patients were not selected on the basis of age; their ages ranged between 15 and 93 years and 19% were older than 70 years. The series included aneurysms located in both anterior and posterior circulations. Eighty-eight percent of all patients underwent surgery and only 2.5% of the series were selectively withdrawn (by family request) from the prescribed surgical treatment. In patients with good grades (WFNS Grades I-III) the 3-month postoperative outcomes were independence (good outcome) in 84% of cases, dependence (poor outcome) in 8% of cases, and death in 9%. In patients with poor grades the outcomes were independence in 40% of cases, dependence in 15% of cases, and death in 45%. There was a 12% rate of rebleeding with all cases of rebleeding occurring within the first 12 hours after SAH; however, outcomes of independence were achieved in 46% of cases in which rebleeding occurred (43% mortality rate). Rebleeding was more common in patients with poor grades (20% experienced rebleeding, whereas only 5% of patients with good grades experienced rebleeding). The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early rebleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.