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Journal of Neurosurgical Sciences 2015 Sep 09

lingua: Inglese

Surgical and endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Bing Z. 1, Rabinstein A. 2, Murad M. H. 3, Lanzino G. 1, Panni P. 4, Brinjikji W. 5

1 Department of Neurosurgery, Mayo Clinic, Rochester, MN;
2 Department of Neurology, Mayo Clinic, Rochester, MN;
3 Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, MN;
4 San Raffaele University Hospital, Milan, Italy;
5 Department of Radiology, Mayo Clinic, Rochester, MN


BACKGROUND AND PURPOSE: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. We evaluated trends in outcomes and treatment of poor-grade aSAH and performed a meta-analysis evaluating outcomes by treatment modality.
METHODS: We performed a literature search for studies on surgical and endovascular treatment of poor-grade aSAH. We performed a random effects meta-analysis evaluating long-term good neurological outcome, long-term poor neurological outcome and mortality, comparing rates between endovascular and surgical treatments. We performed a subgroup analysis of outcome by treatment timing relative to the aSAH separating treatment timing into three categories: 1)ultra-early (within 48 hours of aSAH), 2) early ( between 48 hours-1 week post-aSAH) and 3) delayed (>1 week post-aSAH). We also evaluated trends in treatment modalities and good neurological outcome.
RESULTS: Eighty-five non-comparative studies with 4506 patients with poor-grade aSAH were included. The proportion of patients receiving endovascular treatment increased from 10.0% to 62.0% between 1990-2000 and 2010-2014. The rate of good neurological outcome increased from 37.0% to 44.0% over this time period. Long-term good neurological outcome was 38% (95%CI=33-43%) in the endovascular group and 39% (95%CI=34-44%) in the surgical group (P=0.74). Mortality rates were higher in the endovascular group compared to the surgical group (41% versus 31%, P=0.01). Overall, patients receiving ultra-early treatment had the highest rates of good neurological outcome (61% compared to 40% for early and 47% for delayed, P<0.01).
CONCLUSIONS: Good neurological outcome rates are similar between surgery and endovascular treatment of poor grade aSAH. Ultra-early treatment is associated with improved clinical outcomes.

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