Outcomes following acute poor-grade aneurysmal subarachnoid bleed - Is early definitive treatment better than delayed management?

ABSTRACT Background/Objective Patients with poor-grade subarachnoid bleed (pSAH, World Federation of Neurosurgeons grades 4-5) often improve their neurocognitive function months after their ictus. However, it is essential to explore the timing of intervention and its impact on long-term outcome. We compared the long-term outcomes between immediate management within 24 hours (IM) and delayed management after 24 hours (DM) in patients following pSAH. Methods This was a retrospective population-based study, including patients with pSAH who received definitive management between 1 st January 2011 and 31 st December 2016 in a large tertiary neurocritical care unit. The primary outcome was adjusted odds ratio (OR) of favourable outcome (Glasgow Outcome Scale (GOS) 4-5) for survivors at 12 months following discharge, as measured by the Glasgow Outcome Scale (GOS). The secondary outcomes included adjusted OR of a favourable outcome at discharge, three months and six months following discharge and survival rate at 28 days, three months, six months and 12 months following haemorrhage. Results 111 patients were included in this study: 53 (48%) received immediate management (IM) and 58 (41%) received delayed management (DM). The mean time delay from referral to intervention was 14.9±5.8 hours in IM patients, compared to 79.6±106.1 hours in DM patients. At 12 months following discharge, the adjusted OR for favourable outcome in IM versus DM patients was 0.96 (CI 0.17, 5.39; p=0.961). At hospital discharge, three months and six months, the adjusted OR for favourable outcome was 3.85 (CI 1.38, 10.73; p=0.010), 1.04 (CI 0.22, 5.00; p=0.956) and 0.98 (CI 0.21, 4.58; p=0.982), respectively. There were no differences in survival rate between the groups at 28 days, three months, six months and 12 months (71.7% in IM group vs 82.8% in DM group at 12 months, p=0.163). Conclusions IM and DM after pSAH are associated with similar morbidity and mortality at 12 months. Therefore, delaying intervention in poor-grade patients may be a reasonable approach, especially if time is needed to plan the procedure or stabilise the patient adequately.