Role of emergency surgery to reduce mortality from rebleed in patients with aneurysmal SAH.

Potentially salvageable patients with aneurysmal subarachnoid hemorrhage may rebleed and die after admission to a hospital, awaiting an angiogram or surgery. In an attempt to reduce the number of patients thus lost, we are operating on such patients on an emergency basis. This report is a retrospective analysis of patients operated early after aneurysmal SAH, but during routine working hours, versus patients operated on an emergency basis. During an 18 month period 109 patients underwent surgery for intracranial aneurysm. Fifty two (Group 1) patients were subjected to emergency clipping of the aneurysm, and 57 (Group 2) patients underwent early clipping but during routine working hours. There was no selection bias between the two groups. Another 10 patients in Hunt and Hess Grade II and III rebled and died, after admission, awaiting an angiogram or surgery. The overall mortality for the two groups (Grade I to IV) was 11.9%. Mortality in Groups 1 and 2 was 9.6% and 14.0% respectively. At 1 month, good outcome was recorded in 86.6% patients in grade I, 69.2% patients in grade II and 42.8% patients in grade III in group I compared to 68.7% patients in grade I, 80% patients in grade II and 31.5% patients in grade III in group 2. However, the difference was not statistically significant. There was also no significant difference between the incidence of intraoperative brain swelling and delayed ischaemic neurological deficit between the two groups. Grade IV patients had a poor outcome in both the groups. Angiographic vasospasm was associated with poor out come, in either group, in grade IV patients. Patients in Grades I to III should undergo emergency surgery, if the surgeon is experienced and willing to operate at odd hours and necessary support facilities of neuroradiology and neuroanaesthesiology are available. This would avoid deaths in patients awaiting angiograms or surgery.