Introduction: The optimal timing of treatment for ruptured intracranial aneurysms (RIAs) remains controversial. Ultra-early treatment (within 24h) has been proposed to minimize rebleeding rates and improve outcomes. The purpose of this study was to determine the impact of ultra-early microsurgical clipping of RIAs on clinical outcomes.
Methods: A 5-year, single-institution database of RIAs was used to identify patients treated with microsurgical clipping. Patients were divided by timing to intervention into: Group A (treated within 24 hours) and Group B (treated after 24 hours). Outcomes were measured using the modified Rankin Scale (mRS) at time of discharge.
Results: Sixty-five patients underwent microsurgical clipping within 24 hours (group A) and 50 patients were treated after 24 hours (group B). Age, and prevalence of smoking, hypertension, diabetes and coronary artery disease were comparable between groups. Mortality was significantly higher in Group A (17.2% vs. 4.2% in group B, p=0.04) group A, had a higher rate of extraventricular drain (EVD) placement on arrival (68.3% vs. 34.7%, respectively; p < .001). Functional outcomes by mRS were comparable in both groups when stratified by Hunt-Hess (HH) clinical grade (HH 1-2, p =.890; HH 3, p =.419; HH 4-5, p=.338). A weakly negative correlation between time to microsurgical clipping and mRS at discharge was identified (ps= - 0.21; 95% CI [-0.38 – (-0.02)]; p=0.030).
Conclusions: Although ultra-early treatment was associated with increased mortality, patients in this group presented with higher HH grades and worsening hydrocephalus requiring CSF diversion. Despite increased EVD rates in the ultra-early group, mRS at discharge remained comparable among survivors in both groups. Case controls of ultra-early patients treated after 24hrs or randomized treatment times of clinically comparable cases are needed to establish its full impact on patient outcomes.
Patient Care: Ultra-Early treatment of ruptured intracranial aneurysms has the potential to decrease rebleeding and improve clinical outcomes, understanding the impact of determining factors such as higher clinical grade and hydrocephalus on outcomes will facilitate adequate selection of treatment times.
Learning Objectives: By the end of this presentation, members should be able to:
1.) Recognize the difference between “ultra-early” and “delayed” timeframes for ruptured intracranial aneurysms
2.) Understand the impact of ultra-early treatment on patient outcomes after SAH
3.) Describe the impact of clinical SAH grade and hydrocephalus on outcomes after microsurgical clipping of ruptured intracranial aneurysms