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Ebs sah 2012

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Ebs sah 2012

  1. 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 1
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  6. 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 6
  7. 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 7
  8. 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 8
  9. 9. http://libguides.mq.edu.au/content.php?pid=1 7579&sid=1412020Search strategy EBS presentation 9
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  24. 24. SCOPUS EBS presentation 24
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  28. 28. Author Article Journal No Mortality Favorable outcome Ultra-Early Surgery for Poor-Grade Intracranial Jian-Wei Pan 2009 Aneurysmal Subarachnoid Hemorrhage Yonsei Med J 9 22% 44% Results of early surgery in poor-grade aneurysm Journal of Neurosurgical 52% (HH IV) 22% Zentner J 1996 patients Sciences 85 29% (HH V) Modulated surgery in the management of ruptured Steudel, W.-I 1994 intracranial aneurysm in poor grade patients Neurological Research 116 23% 56% Results of early aneurysm surgery in poor-grade Spetzger, U. 1994 patients Neurological Research 76 28% 54% Management morbidity and mortality in grade IV and V patients with aneurysmal subarachnoid Seifert, V. 1990 haemorrhage Acta Neurochirurgica 74 31% (HH IV) 53% (HH IV) Management morbidity and mortality of poor-grade Bailes JE 1990 aneurysm patients. J Neurosurg 34 23% 54% Patients in Poor Neurological Condition after Subarachnoid Hemorrhage: Early Management and G. Rordorf 1997 Long-Term Outcome Acta Neurochirurgica 118 30% 47% Management morbidity and mortality of poor-grade Julian E. B 1990 aneurysm patients Neurosurg 35 23% 65% Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of John D. Laidlaw 2002 391 patients not J Neurosurg 177 45% 40% Aneurysm surgery of patients in poor condition. Ungersbo ̈ck et al 1994 Indications and experience. Neurol Res 27 22% 11% Modulated surgery in the management of ruptured Steudel et al 1994 intracranial aneurysm in poor grade patients Neurol Res 57 23% 56% EBS presentation 28 Outcome after Urgent Surgery for Grade IV Bryan J. Duke 1998 Subarachnoid Hemorrhage Surg Neurol 27 33% 59%
  29. 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 29
  30. 30. - Observational retrospective case series- HH IV and V before and after EVD- All patients except those who showed CT scanevidence of destruction of critical areas had EVD- 97 surgery, 26 endovascular, <24h- Mortality 30% for treatment (100% for nosurgery)- Outcome 1y: 47% good outcome aftertreatment EBS presentation 30
  31. 31. - Cohort study- HH IV-V- 35 Pt surgery EBS presentation 31
  32. 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 32
  33. 33. • Early surgery for HH I-III: – 90% good neurological recovery range – Mortality 1.7-8% EBS presentation 33
  34. 34. • Rebleeding maximal in the first 24 h (4%)• Second haemorrhage increases mortality to approximately 70%• EBS presentation 34
  35. 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 35
  36. 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 assessed Intracerebral blood clot? Surgical challange in hostile conditions? Endovascular treatment? General medical conditions? Neurological and radiological deep brain lesions? Age? …… EBS presentation 36
  37. 37. Thank you EBS presentation 37

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