Every day counts for ruptured aneurysm treatment

By Eleanor McDermid

Patients with ruptured intracranial aneurysms should undergo treatment as soon as they become eligible, shows an analysis of the International Subarachnoid Aneurysm Trial (ISAT).

The findings were consistent for patients randomly assigned to undergo endovascular coiling and those allocated to undergo surgical clipping.

"Historically, clipping between days 5 to 10 is considered the worst period for neurosurgery," say Sanne Dorhout Mees (University Medical Center Utrecht, the Netherlands) and colleagues.

"Interestingly, in our study, the risk for DCI [delayed cerebral ischemia] was low in patients clipped during this time, and outcome was not worse when compared with treatment after day 10," they write in Stroke.

"On the basis of the current evidence, there seems no reason to postpone treatment in patients who are eligible for treatment at day 5."

In all, 2106 patients were treated in ISAT, of whom 891 received treatment within 2 days after subarachnoid hemorrhage (SAH), 482 within 3-4 days, 474 within 5-10 days, and 259 were treated more than 10 days after SAH.

In contrast with results in clipped patients, rates of DCI were elevated in patients who underwent coiling within 5-10 days after SAH, at a 1.68-fold increase relative to patients whose aneurysms were coiled within 2 days.

But this did not appear to affect outcomes. Relative to patients who underwent coiling within 2 days after SAH, those treated within 3-4 days and 5-10 days had respective nonsignificant 1.27- and 1.17-fold increases in the risk for poor 2-month outcomes, defined as a modified Rankin Scale score of 3 or higher.

For clipped patients, those treated within 3-4 days had a nonsignificant 1.03-fold increase in the risk for poor outcomes and patients treated within 5-10 days had a significant 1.46-fold increase in risk. The findings were adjusted for age, clinical condition at admission, and amount of blood on the baseline computed tomography scan.

Outcomes were worst in patients treated more than 10 days after SAH. Coiled patients had a 1.73-fold and clipped patients a 1.61-fold increase in risk, relative to those treated within 2 days of SAH.

"It is important to realize that patients were not randomized for the timing of treatment, and the worse outcome in this group is probably related to the reasons for postponing treatment, such as poor clinical condition on admission, early rebleeding, or early deterioration from other causes," says the team.

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